
Oass_JS£ s 3JL! 

Book j(uj IS 



COPYRIGHT deposit. 



PULMONARY TUBERCULOSIS 

A HANDBOOK FOR STUDENTS 



BY 

EDWARD 0/^)TIS, M.D. 

Professor of Pulmonary Diseases and Climatology, Tufts College Medical School, 
Boston; Formerly Visiting and Consulting Physician to the Massachusetts 
State Sanatorium (Rutland); Fellow and Former President of the 
American Climatological and Clinical Association; Corres- 
ponding Member of the International Tuberculosis 
Institute; Consulting Physician to the Boston 
Dispensary, Tuberculosis Department, etc. 



"This is the malady which the ancients 
did call tabes, or the wasting disease, and 
some do name consumption." 

Master Giles Firmin 



BOSTON 

W. M, LEONARD, Publisher 

1917 



"*c»* 



-)•£ 



Copyright, 1917 
By W. M. Leonard 



/ 

MAY -3 1917 

©CI.A480586 
1^0 | 



TO THE LATE 

FREDERICK IRVING KNIGHT, A.M., M.D. 

A man of profound knowledge and great 

experience in Tuberculosis 

Teacher, Writer, and Worker in the 

Prevention of the Disease 



PREFACE 

The author has been engaged in teaching the sub- 
ject of pulmonary tuberculosis for a considerable 
number of years, and this manual is largely the 
result of his experience. It is primarily intended 
for students of the third and fourth years, to be 
used in connection with clinical work. It is also 
hoped that the book may not be without value to 
physicians who desire briefly to refresh themselves 
upon this ever-recurring disease. Such a handbook 
must obviously omit much which properly finds its 
place in large, exhaustive treatises upon the subject. 
The object has been to give the main essential facts, 
emphasizing them in accordance with the author's 
experience and judgment. 

One of the difficulties of the student in making an 
early diagnosis of pulmonary tuberculosis is his in- 
ability to correlate the symptoms and physical signs, 
and to give to each symptom and sign its due pro- 
portionate weight; and in this handbook an attempt 
has been made to aid him in this respect. 

The diagnosis of early clinical pulmonary tuber- 
culosis is easy or difficult much according to the 
way in which the student sums up his evidence from 
the examination of the patient and the emphasis he 
places upon the various symptoms and signs. Noth- 



PREFACE 

ing, of course, will take the place of much clinical 
work under expert guidance, but it is hoped that 
this manual will be of assistance in connection with 
such work and enable the student to lay a founda- 
tion upon which he can firmly build from future 
experience and study. 

The method and arrangement are those which the 
author has found serviceable in presenting the sub- 
ject to his classes. Most of what the book contains 
is the common knowledge of the physician, and only 
the attempt has been made to so present this know- 
ledge as to give the student a clear conception of the 
subject as a whole that he may not underrate cer- 
tain aspects of it and exaggerate others. Many 
authorities have been consulted, to all of which the 
author makes his acknowledgments. 

E. O. O. 

Boston, 191 7 



CONTENTS 

CHAPTER PAGE 

I Anatomy and Physiology i 

II The History of Tuberculosis 22 

III Pathology and Bacteriology 34 

IV Diagnosis 52 

V Diagnosis (Continued) 75 

VI Prognosis 99 

VII Treatment 109 

VIII Especial Methods of Treatment .... 133 

IX Treatment of Special Symptoms . . . .141 

X Tuberculosis in Children 160 

XI Climate in the Treatment of Tuberculosis 166 

XII Prophylaxis 178 

XIII Aftercare and Marriage 185 

XIV Cases 192 



CHAPTER I 

ANATOMY AND PHYSIOLOGY 

"Anatomy studies the organism in space, physiology 
studies it also in time." 

O. W. Holmes 

In order to intelligently study the disease of any 
organ, a knowledge of its normal anatomy and 
topographical relations, and its physiological func- 
tion is essential. Although this knowledge as ap- 
plied to the lungs and their surroundings is sup- 
posed to have been already obtained in the courses 
upon anatomy and physiology, a brief review in 
this connection will not be without value in the 
further study of this subject. 

The Bony Framework of the Chest 
The lungs are contained in the bony framework 
of the chest which serves both as a protecting shield 
for the enclosed organs and as a mechanical device 
in conjunction with the respiratory muscles for pro- 
ducing the movements of respiration. 

This framework (Fig. i) is composed of the 
thoracic spine, to the bodies and transverse pro- 
cesses of which are attached the ribs, and the 
sternum, to which the ribs are united by cartilages. 
The thoracic spine consists of twelve thoracic verte- 



2 PULMONARY TUBERCULOSIS 

brae, and has a hackwork convexity. The ribs, 
somewhat circular in shape, are attached to the 
spine with varying degrees of obliquity, but all, 
however, slope downward, outward and forward. 

Movement of the Ribs 

The ribs are articulated with the vertebrae in such 
a way that they form a sort of hinge of limited 
motion so that in the movements of respiration they 
swing on the fixed spine, up and down, and when 
elevated in the act of respiration they push the 
sternum forward and thus increase the antero- 
posterior diameter of the chest, and at the same 
time the intercostal spaces are widened. Another 
motion also takes place when the ribs rise : they 
describe a rotary motion outward around an imag- 
inary axis which unites with the two ends of the 
ribs, and thus the transverse diameter of the chest 
is increased. 

Intercostal Spaces 

The intercostal spaces differ in size, being larger 
between the upper ribs than the lower. The sec- 
ond, third, tenth and eleventh interspaces are the 
widest, and the widest part of each individual space 
is near the anterior part of the ribs. These spaces 
are closed by the intercostal muscles. Lying in a 
sort of gutter under the rib, at its lower border, are 
the intercostal artery, vein and nerve; in aspirating 
the chest, consequently, the arm on the affected 
side should be brought forward with the hand 




Fig. I 



ANATOMY AND PHYSIOLOGY 3 

placed on the opposite shoulder so as to widen the 
interspace, and the aspirator needle thrust in at 
right angles close to the upper margin of the rib 
so as to avoid wounding these vessels. 

Counting the Ribs 
It is often necessary to count the ribs and it is 
sometimes difficult to do so directly, so that it is 
helpful to have some landmarks. The following 
are given by Holden : 

(a) " The angle of Ludovici, formed by the 
manubrium and gladiolus, is at the second rib." 

(b) " The nipple of the male is placed, in the 
great majority of cases, between the fourth and 
fifth rib." 

(c) " The lower external border of the pectoralis 
major corresponds with the direction of the fifth 
rib." 

(d) "A line drawn horizontally from the nipple 
round the chest cuts the sixth intercostal space mid- 
way between the sternum and the spine." (This is 
a useful guide in tapping the chest.) 

(e) " When the arm is raised the highest visible 
digitation of the serratus magnus corresponds with 
the sixth rib, the digitations below this correspond 
respectively with the seventh and eighth ribs." 

(f ) " The scapula lies on the ribs from the sec- 
ond to the seventh inclusive." 

(g) " The eleventh and twelfth ribs can be felt 
even in corpulent persons outside the erector spinse, 
sloping downward." 



4 PULMONARY TUBERCULOSIS 

(h) " One should remember the fact that the 
sternal end of each rib lies on a lower plane than its 
corresponding vertebra " ; for instance, a line drawn 
horizontally backward from the middle of the third 
costal cartilage, at its junction with the sternum, 
to the spine, would touch the body not of the third 
dorsal vertebra but of the sixth. Again, the end of 
the sternum would be on about the level of the tenth 
dorsal vertebra. Much latitude must be allowed 
here for variation in the length of the sternum, 
especially in women." 

Diaphragm 

The base of the thoracic cavity is closed by the 
diaphragm, a dome-shaped muscle attached to the 
ensiform cartilage in front, to the cartilages and 
bony portions of the sixth and seventh inferior ribs 
on each side, and behind to two aponeurotic arches 
and to the lumbar vertebrae. 

The diaphragm acts actively in conjunction with 
the intercostal muscles in inspiration, while in ex- 
piration it becomes passive and is pushed up by the 
action of the abdominal muscles. By the contrac- 
tion of the diaphragm in inspiration the chest is 
enlarged in its vertical direction. When the chest 
hr. .; become very rigid, or when the intercostal 
muscles are paralyzed, the diaphragm becomes the 
chief or only muscle of respiration. Also in ordi- 
nary tranquil breathing of the sedentary person this 
muscle does most of the work of respiration 
(abdominal respiration), as can be readily observed 



ANATOMY AND PHYSIOLOGY 5 

in watching the chest of a person at rest. Inter- 
ference with the free movement of the diaphragm 
by a distended stomach or fluid in the peritoneum 
causes dyspnoea. No other muscle in the body, ex- 
cept the heart muscle, works so unceasingly as the 
diaphragm. Day and night, from birth to death, 
with only periods of rest of seconds, this faithful 
muscle does its duty. It is a very powerful muscle, 
and Campbell speaks of a man whom he knew who 
could move a grand piano by means of it. In 
forced inspiration the diaphragm is displaced down- 
ward three and one-half inches, which can be de- 
termined by the extension of resonance on per- 
cussion. The fluoroscope and the " Litten's phe- 
nomenon " indicate visibly the movements of the 
diaphragm. In early pulmonary tuberculosis the 
excursion of the diaphragm is diminished on the 
affected side, as can be demonstrated by the fluoro- 
scope. I do not, however, consider this a very im- 
portant diagnostic sign. 

The Thoracic Cavity and Pleurae 
The top of the thoracic cavity is shut in by the 
muscles about the neck. The interior of the cavity 
is lined by the pleurae, a serous membrane whose 
chief function is to enable the lungs to expand 
equally in all directions. 

When pleural adhesions occur from inflamma- 
tion of the pleurae, this free movement of the lungs 
is impeded, and this may be one reason why the 
apices of the lungs are so prone to tubercular in- 



6 PULMONARY TUBERCULOSIS 

f ection ; hence, as Campbell points out, " those with 
pleuritic adhesions should frequently resort to cos- 
tal breathing." When the pleurae are normal, they 
are smooth and frictionless, and their inner surface 
is constantly lubricated with the serous fluid, so that 
the two layers slide freely upon each other and the 
movement of the lungs in respiration causes no sen- 
sation; if, however, the pleurae become roughened 
by inflammation, one experiences a " pleuritic 
pain " on breathing, and hence the reason for 
strapping the chest over the affected side to restrict 
the respiratory movement and thus lessen the pain. 
There is a right and left pleura separated by a 
space called the mediastinum which contains the 
heart and great vessels. Each pleura is two- fold, 
an outer parietal layer which is thick and feebly 
adherent to the inner wall of the chest throughout 
its entire extent and is reflected upon the superior 
surface of the diaphragm below, and above it ex- 
tends through the upper opening of the thorax into 
the neck; and an inner or visceral layer which is 
extremely delicate and very transparent. It is very 
adherent to the lungs and invests them completely, 
dipping to the bottom of the fissures which divide 
the lungs into lobes. 

Cavity of the Pleura 
The interspace between the two layers of the 
pleura is called the cavity of the pleura, which nor- 
mally is closed, the parietal and visceral layers being 
in apposition. When, however, an effusion occurs 



ANATOMY AND PHYSIOLOGY 7 

the two layers are separated by the fluid, and when 
also the operation of artificial pneumothorax is per- 
formed the gas likewise separates the two layers, 
compressing the lung. The pleural cavity shows 
a negative pressure, and when opened the positive 
pressure of the outside air instantly collapses the 
lung. When the opening to the outside air, how- 
ever, is closed, the air inside is slowly absorbed and 
the lung expands again. When from disease an 
opening from the lungs into the pleural cavity oc- 
curs, the lung is likewise collapsed and a pneumo- 
thorax is formed, the pressure from the inside being 
the same as that of the outer air. The parietal or 
costal layer of the pleura is attached to the chest 
wall by connective tissue and when from an injury 
or puncture, as in artificial pneumothorax, air enters 
into the space between the chest wall and costal 
pleura, a deep emphysema is developed. 

When the cavity of the pleura requires tapping to 
evacuate fluid the sixth or seventh intercostal space 
midway between the sternum and spine is usually 
selected. 

The right and left pleural cavities are separate 
and distinct; and the parietal pleura, at the point 
of its reflection upon the upper part of the dia- 
phragm is called the inferior cul-de-sac of the 
pleura; hence, we can have diaphragmatic pleurisy. 

Lymphatics of the Pleurae 

The lymphatics of the pleura are abundant, both 
in the parietal and visceral layers, those of the latter 



8 PULMONARY TUBERCULOSIS 

connecting with the lymphatics of the lungs, and 
those of the former with the lymphatics of the 
thoracic wall. It is through this lymphatic system 
in conjunction with the respiratory movements that 
the pleuritic fluid is chiefly absorbed. 

The Lungs 

The lungs fit into the pleura-lined chest, the 
rounded apex projecting about one and one-half 
inches above the sternal end of the clavicle and the 
concave base fitting accurately upon the convex top 
of the diaphragm. The lower limit of the lungs 
can be represented by a line drawn around the chest 
from the junction of the sixth costal cartilage with 
the sternum to the spinous processes of the tenth 
dorsal vertebrae. The right lung (Fig. 2) is 
shorter and broader than the left and has three lobes 
and two fissures. The left lung (Fig. 3) has two 
lobes and one fissure. The lungs occupy four-fifths 
of the thoracic cavity, the remaining space being 
occupied by the heart and hilus of the lungs, formed 
by the bronchi, the pulmonary artery and vein, the 
lymphatic vessels, nerves and glands. 

The normal weight of the lungs varies between 
1 100 and 1200 grams (5 or 6 lbs.) in the male, 
and 900 to 1 100 grams (4.1 to 5 lbs.) in the female. 

The substance of the lungs is of a spongy texture, 
consisting of a mass of minute cavities — the 
alveoli — which are encircled by a mesh of capillary 
vessels only separated from the air by the exceed- 
ingly thin membrane of the alveoli, By this 




Fig. 2. The Right Lung 




Fig. 3. The Left Lung 



ANATOMY AND PHYSIOLOGY 9 

mechanism the oxygen entering the lungs is ab- 
sorbed by the blood and carbon dioxide, nitrogen 
and watery vapor excreted. Elastic tissue enters 
largely into the composition of the lungs and upon 
this elastic tissue their expansibility depends. 
When the chest is opened the lungs collapse to about 
a third of their ordinary size. In emphysema of 
the lungs this elasticity is to a great extent lost 
and, in consequence, they are in a constant state of 
distension. 

The general shape of the lungs is triangular, or 
conical, and is conformed to the shape of the 
thoracic cavity. In front the anterior edges of the 
lungs do not come together in tranquil breathing, 
while in forced inspiration they meet over the base 
of the heart. The anterior edge of the right lung 
is nearly vertical, while that of the left is oval or 
oblique. 

Boundaries of the Lungs and Lobes 

Above, the lungs extend about one and one-half 
inches beyond the sternal end of the clavicle; below, 
from the sixth costal cartilage of the sternum to 
the spinal processes of the tenth dorsal vertebrae. 
The following table will be useful in fixing in one's 
mind the boundaries of the lobes: 

Right Lung; Three Lobes 

Anteriorly Laterally Posteriorly 

Upper Apex to To Fourth Rib Apex to Spine 

Lobe Fourth Rib of Scapula 



io PULMONARY TUBERCULOSIS 





Anteriorly 


Laterally 


Posteriorly 


Middle 
Lobe 


Fourth Rib to 
Inferior An- 
gle of Sixth 
Rib 


Fourth to 
Sixth Rib 


Nil. 


Lower 
Lobe 


Nil. 


Sixth to 

Eighth Rib 


Spine of Scap- 
ula to Tenth 
Rib 




Left Lung 


; Two Lobes 




Upper 
Lobe 


Apex to Sixth 
Rib 


To Fourth Rib 


Apex to Spine 
of Scapula 


Lower 
Lobe 


Nil. 


Fourth Rib to 
Base 


Spine of Scap- 
ula to Tenth 
Rib 



One can easily remember that in front on the 
right side we have the upper and middle lobe (Fig. 
4), and on the left the upper lobe (Fig. 5), while 
behind we have an upper and lower lobe on each 
side. It is helpful to remember the boundaries of 
the lobes of the lungs, and particularly to bear in 
mind how large a part of the organ, posteriorly, 
consists of the lower lobe. It is of aid in determin- 
ing the extent of a pneumonic consolidation ; 
whether or not a tuberculous process has invaded 
the lower lobe; and in making a diagnosis between 
solidification of the lower lobe and an effusion. 

Lymphatics of the Lungs 

The lymphatics of the lungs, which are abundant, 
are superficial and deep and terminate at the root of 
the lungs in the bronchial glands, which lie along 
the lower portion of the bronchi and trachea. 




Fig. 4. Longitudinal section through the right mammary line 
From Garre und Quincke, Lungenchirurgie 







' 






^ 


JBFS 










"@wEi 


ftmk 




v^BI 








fwNr 


j 


ra! 






«vl-m 












# /li/ - ^^ 






-' '' MHk^4f4Sffi 




KyHnf. ^P : . : 


• ^ >•-.-;• i^ 




' »'- ■« If 


'iv'Mr >■■ 






WmLz/m 




WS£Wmt { 






wML'fvUfe 






WiWl 


y .mwHffiHJlS 




K irVJUlK 



Fig. 5. Longitudinal section through the left mammary line 
From Garre und Quincke, Lungenchirurgie 



ANATOMY AND PHYSIOLOGY n 

These glands readily enlarge in various infectious 
diseases, particularly in tuberculosis. Such en- 
larged glands can be detected by the X-ray and 
also sometimes can be made out with more or less 
definiteness by percussion and auscultation. When 
much enlarged they give rise to cough and dyspnoea 
(Fig. 6). (Fig. 6a.) 

The Bronchi and Trachea 

The lungs are connected with the outer air by 
means of the bronchi and trachea. The latter 
starts opposite the lower border of the sixth cervi- 
cal vertebra and ends between the fourth and fifth 
thoracic vertebrae. It is four to four and one-half 
inches long, and bifurcated into the bronchi just 
above the level of the junction of the manubrium 
sterni and gladiolus. The right bronchus follows 
more nearly than the left the course of the trachea. 
From the two main stems are given off lateral 
branches and these divide and subdivide until at 
last they terminate in the lobules and these again 
in the intercellular passages and air cells. 

The bronchi are accompanied by branches of the 
pulmonary artery, the lymphatics and nerves. The 
arch of the aorta is in close relation with the left 
bronchus and in aortic aneurysm we may have 
partial or complete obstruction of the bronchus, 
and as a result the development of acute bron- 
chiectasis. 



12 PULMONARY TUBERCULOSIS 

Landmarks of the Lungs (Holden) 
i. " The apex of each lung rises into the neck 
behind the sternal end of the clavicle and the sterno- 
mastoid muscle about one and one-half inches." 

2. " There is little or no lung behind the first 
bone of the sternum." 

3. " From the level of the second costal cartilage 
to the line of the fourth the margins of the lungs 
run parallel, or nearly so, close behind the middle 
of the sternum." 

4. " Below the level of the fourth costal cartilage 
the margins of the lungs diverge, that of the right 
corresponds with the direction of the cartilage of 
the sixth rib, while that of the left being notched 
for the heart, runs behind the cartilage of the 
fourth rib. A line drawn perpendicularly from the 
nipple would find the lung margin about the lowest 
part of the sixth rib." 

5. " In deep inspiration the lung margins descend 
about one and one-half inches." 

The Shape of the Chest and Its Modification by 
Disease 

In the normal chest the antero-posterior diameter 
is about one- fourth less than the transverse dia- 
meter. The horizontal section of the chest shows 
the general form of an ellipse. The adult female 
chest is generally more barrel-shaped than the male 
chest. As abnormal modifications, we have: 

(a) The emphysematous chest which is more or 
less barrel-shaped. 




Fig. 6. The relationship of the bronchial glands to the an- 
terior thoracic walls 

From Stoll — "American Journal of Diseases of Children" — 1912 — 
vol. 4. 333-359 




Fig. 6a. The relationship of the bronchial glands to the pos- 
terior thoracic walls 

From Stoll — "American Journal of Diseases of Children" — 1912 — 
vol. 4. 333-359 



ANATOMY AND PHYSIOLOGY 13 

(b) The flat chest, the so-called "phthisical 
chest," although a flat chest does not necessarily 
indicate a tendency to tuberculosis. 

(c) The " pigeon-breasted," also called the " keel 
chest " which is characterized by its triangular 
shape: the sternum is pushed forward, increasing 
the antero-posterior diameter. This deformity is 
caused by a long existing impediment to free in- 
spiration, such as enlarged tonsils, adenoids, or by 
chronic bronchitis or whooping cough. 

(d) The rachitic chest where there is a lateral 
compression of the chest walls and a relative in- 
crease in the antero-posterior diameter. 

(e) The funnel, gutter or cobbler's chest, char- 
acterized by a depression of the lower part of the 
sternum. This formation may be the result of 
rickets, or it may be congenital or acquired, as in 
the case of the cobbler. 

(f) The "Alar-chest," in which the angles of 
the scapulae project which gives them a wing-like 
appearance. Such a chest is generally of small 
capacity and is supposed to suggest a predisposi- 
tion to tuberculosis. 

We have also unilateral changes in the chest : one 
side may be increased in size over the other, as from 
pleural effusions, pneumothorax, or compensatory 
hypertrophy ; or one side may be retracted, as from 
tubercular contractions, the result of long compres- 
sion of the lung by pleural effusion, or of an 
empyema. 

Again, we may have local changes in the shape 



i 4 PULMONARY TUBERCULOSIS 

of the chest, such as bulging in the lower anterior 
or lateral region, as in the case of empyema where 
the pus tends to be evacuated; or a contraction 
above and below the clavicle, which is frequently 
observed in tuberculosis. Other causes are atelec- 
tasis, bronchiectasis, and pleural adhesions. 

Physiology of Respiration 

Respiration consists of two separate acts, inspira- 
tion, which is essentially active, and expiration, 
which is almost entirely passive. The muscles en- 
gaged in ordinary inspiration are the intercostals, 
the diaphragm, the levatores costorum, scaleni and 
serati postici. The movements of expiration are 
chiefly due to the elasticity of the lungs and the pas- 
sive return of the diaphragm and chest walls. In 
ordinary quiet breathing there is comparatively 
little rib movement, especially in the upper half of 
the thorax, inspiration being almost entirely ab- 
dominal. This is less so with women. In extra- 
ordinary inspiration many other muscles come into 
play, — indeed, all the muscles about the chest, 
which by fixing their point of attachment can aid 
in elevating the ribs and expanding the chest, such 
as the pectorals, latissimus dorsi, quadrati lum- 
borum, sterno-mastoid, erector spinae and infra- 
hyoid. In a severe attack of asthma, for example, 
many of these muscles can be seen at work in a 
frantic attempt to get more air into the lungs. Any 
impediment to the free movements of the chest or 
action of the muscles of respiration obviously inter- 



ANATOMY AND PHYSIOLOGY 15 

fere with free adequate respiration. Such impedi- 
ments may be pathological or mechanical. Of the 
former we may have diseases of the lungs, pleural 
effusions, aneurysm of the aorta, curvature changes 
in the thoracic walls, ascites, peritonitis, abdominal 
tumors, etc. Of the latter — mechanical — are 
posture, flatulent distension of the stomach, con- 
striction, like tight corsets. 

The general movement of the chest is also greatly 
diminished in emphysema, in certain cases of 
asthma, and from injuries to or diseases of the 
spinal cord which paralyze the muscles of respira- 
tion. The movements of one side of the chest may 
also be diminished, as in pleural effusion, pneumo- 
thorax, pneumonia and tuberculosis. 

Increased expansion occurs during violent exer- 
cise; in the early stages of febrile diseases; from 
various emotional disturbances, and sometimes in 
dyspncea. When in the case of an unilateral tuber- 
culosis increased expansion of the other lung occurs, 
it is a favorable prognostic omen. There is a re- 
traction or general drawing in of the intercostal 
spaces when there is any obstruction to the entrance 
of air, as in croup, the pressure of an enlarged 
thyroid gland, an aneurysm, or a tumor pressing 
on the trachea or bronchi. This also sometimes 
happens in bronchial asthma. 

The relation of the act of inspiration to that of 
expiration is as 5 to 6 ; but the relative duration of 
the sounds, however, are as 3 to 1, while the ex- 
piratory sound is often quite inaudible. 



16 PULMONARY TUBERCULOSIS 

The circumference of the normal chest averages 
34 inches, or 87 cm., and the expansion on forced 
inspiration from one and one-half to five inches, 
or 4 to 13 cm. Much depends upon practice in 
deep breathing. 

Vital Capacity of the Lungs 

The vital capacity of the lungs, or the amount 
of air exhaled on a forced expiration, after a forced 
inspiration, is about 230 or 240 cubic inches, or 
3600 c.c. in men and 150 cubic inches, or 2500 
c.c. in women. In one thousand observations 
which I made upon males from sixteen to forty 
years of age, I found the average to be 240 cubic 
inches. The vital capacity is measured either by 
the water or dry spirometer. The vital capacity is 
generally diminished in all diseases of the respiratory 
organs, and hence this measurement is of some 
value in judging of improvement in a case of tuber- 
culosis, for example. 

The " tidal air," the amount of air inhaled and 
exhaled in quiet breathing, is about 500 c.c or 30 
cubic inches. The " complemental air," the addi- 
tional amount one can take in by forced inspiration, 
is from 1500 to 2000 c.c. or 90 to 120 cubic 
inches ; and the " supplemental air," the additional 
amount one can exhale in excess of the normal tide, 
by forced expiration, is from 1200 to 1500 c.c. or 
72 to 90 cubic inches. The " residual air," what 
is left in the lungs at the end of forced expiration, 



ANATOMY AND PHYSIOLOGY 17 

is estimated at from 1200 to 1500 c.c. or 72 to 
90 cubic inches. 

The following measurements which the writer 
made and collected will serve as fairly accurate 
standards of chest measurements and lung capacity. 
The " muscular " circumference of the chest was 
taken at the level of the nipples and the " respira- 
tory " circumference two inches below : 

Measurements of the Chest and Lung Capacity 

TABLE I 

Chest Measurements 

girth of chest, muscular Repose Inflated Difference 

Men inches inches inches 

Average of Dr. E. O. Otis, 
one thousand measurements, 
between sixteen and forty 

years of age 34.0 36.1 2.1 

Average of Dr. Hitchcock, 
of Amherst College. Eight 

thousand measurements . . 34.6 36.5 1.9 
Average of E. Hitchcock, Jr., 
of Cornell College. Fif- 
teen thousand measure- 
ments 34-5 36.3 1.8 

Women 
Mt. Holyoke and Wellesley 
students. Measurements of 
Miss Wood and Dr. Mary 

Colton 29.5 31.5 2.0 

respiratory chest 
Men 
Average of Dr. E. O. Otis. 
One thousand measurements 31. 1 33-1 2.0 

Women 
Fifty per cent, of fifteen hun- 
dred Wellesley students. 
Miss Wood 24.6 27.2 2.6 



1 8 PULMONARY TUBERCULOSIS 

Measurements of the Chest and Lung Capacity 
Continued. 
depth of chest Repose Inflated Difference 

Men inches inches inches 

Average of Dr. E. O. Otis. 
One thousand measurements 
in repose and one hundred 
and twelve measurements 
inflated 7.3 8.2 0.9 

Women 
Fifty per cent, of fifteen hun- 
dred students at Wellesley. 
Miss Wood 6.9 

breadth of chest 
Men 
Average of Dr. E. O. Otis. 
One hundred and fifty meas- 
urements 9.6 10.8 1.2 

TABLE II 

Capacity of Lungs 

Cubic 
Men Inches 
Average of Dr. E. O. Otis. One thousand measure- 
ments 240.6 

Hitchcock. Eight thousand measurements 230.0 

Hitchcock, Jr. Fifteen thousand measurements .... 236.6 

Women 

Mt. Holyoke and Wellesley students. Measurements 

of Miss Wood and Dr. Mary Colton 145.8 

Fifty per cent, of fifteen hundred Wellesley students. 

Miss Wood 150.3 

TABLE III 
Comparison of the "Vital" or Lung Capacity and the 
Amount of Air Expelled after an Ordinary Quiet In- 
spiration. Average of Dr. E. O. Otis. One Hun- 
dred and Fifty Measurements • 

Cubic 
Inches 
Vital capacity, or the amount of air exhaled after a 

full inspiration 230.5 



ANATOMY AND PHYSIOLOGY 19 

Amount of air exhaled after an ordinary quiet inspira- 
tion , 129.3 

Difference, or " complemental " or " reserve "air 101.2 

Average Lung Capacity for Height 

Average for each inch 
Height. Lung Capacity or Centimeter 

in Height. 

66 to 67 inches, incl. 231.62 o. in. 3-4+c. in. 

167.7 to 170.3 cms. 3,797 c. cms. 22.4 c. cms. 

67 to 68 inches, incl. 237.10 c. in. 3.46 c. in. 

170.3 to 172.8 cms. 3,903 c. cms. 22.7 c. cms. 

68 to 69 inches, incl. 244.44 c. in. 3.5 c. in. 

172.8 to 175.4 cms. 4,007 c. cms. 23.06 c. cms. 

69 to 70 inches, incl. 259.34 c. in. 3.64 c. in. 

175.4 to 177.9 cms. 4,250 c. cms. 24.06 c. cms. 

70 to 71 inches, incl. 261.38 c. in. 3.64 c. in. 

177.9 to 180.5 cms. 4,284 c. cms. 23.9 c. cms. 

71 to 72 inches, incl. 261.34 c. in. 3.5 c. in. 

180.5 to 183 cms. 4,284 c. cms. 23.03 c. cms. 



General average 



3.52 cubic inches. 
23.19 cubic cms. 



As has been said, the expiratory act, although 
essentially passive as regards the muscles of respira- 
tion, takes place by a shrinkage of the lung tissue 
by means of its elasticity. When this elasticity is 
impaired by degenerative changes or disease, ex- 
piration is incomplete or difficult. Normal respira- 
tion occurs at the rate of about 16 times per minute. 
We may say anything between twelve and twenty 
is normal. The ratio of the respiration to the pulse 
rate is about one to four or five. 

Abnormalities of Respiration 

(a) Dyspnoea — difficult, rapid, labored respira- 
tion — occurs in a variety of conditions, such as 
heart disease, pneumonia, extensive pleural ef- 



20 PULMONARY TUBERCULOSIS 

fusion, asthma, tuberculosis, anaemia, and acute in- 
fections. We have both expiratory and inspiratory 
dyspnoea. When both exist, which is commonly 
the case, it is called mixed dyspnoea. Functional 
dyspnoea occurs as a result of violent exercise or 
emotional disturbances. 

(b) Orthophoea: excessive dyspnoea, when the 
patient is obliged to sit up in order to breathe more 
easily. 

(c) Obstructive dyspnoea, from some hindrance 
to free entrance of the air into the lungs, caused by 
various obstructions in the pharynx, larynx, trachea 
or bronchi, such as enlarged tonsils, peritonsillar 
abscess, oedema glottis, foreign bodies in the upper 
respiratory tract, stenosis of the larynx or trachea, 
aneurysm, tumors, etc. 

(d) Apncea: a temporary cessation of breathing, 
illustrated in so-called " Cheyne-Stokes " respira- 
tion, which is characterized by a waning and wax- 
ing of the respiration. Beginning with a number 
of superficial respirations, they gradually deepen 
until full respiration or even dyspnoea is reached ; 
then the respirations decline in force and length 
until a state of apnoea occurs which may last so long 
that one may believe that the patient is dead. 

(e) Asphyxia: a sudden arrest of respiration 
from outward violence, as in choking, or in ap- 
parent drowning. In many instances of apparent 
death from asphyxia, resuscitation may be effected 
by means of artificial respiration at once applied 
and continued for a long time. 



ANATOMY AND PHYSIOLOGY 21 

Other abnormalities of respiration are indicated 
by the names given them, as stertorous, stridulous, 
asthmatic, shallow, jerky, sighing, catchy, re- 
stricted. 

A study of the respiration, both in health and 
disease, is of much value and conveys much useful 
information. Breathing exercises are an important 
preventive measure as well as a valuable aid in 
some of the abnormal conditions of the lungs. 
Proper full respiration is, in modern life, more or 
less of an acquired habit, and it is of importance 
that the physician himself should first learn to 
breathe correctly and then he will be able to teach 
his patients to do the same. There are a few easily 
acquired breathing exercises, both simple and ef- 
ficient, which will develop the chest and increase the 
lung capacity, and which will be of value in prevent- 
ing disease, as well as helpful in the treatment of 
various diseases. For an exhaustive study of this 
subject, one is referred to the treatise upon " Res- 
piratory Exercises in the Treatment of Disease " 
by Harry Campbell, M. D. N. Y. Wm. Wood & Co. 



CHAPTER II 

THE HISTORY OF TUBERCULOSIS 

" Other men labored, and ye are entered into their labors." 

John, iv, 38. 

The world-wide prevalence of tuberculosis, its 
predominant influence in medicine, and its antiquity 
warrant some brief mention of its history, that we 
may learn through what labor and sacrifice our 
present knowledge of the disease has come down to 
us. When and how did tuberculosis have its 
origin? No one knows; all we know is that 
" phthisis " or " consumption," as it was called, has 
existed almost as long as recorded events. As 
some one has expressed it, " it has always existed." 

That celebrated physician of antiquity Hippo- 
crates, who was born about the time of Socrates 
(460-377 b. a), the supposed period of the Jewish 
return from their exile at Babylon, gives the first 
clear clinical description of the disease. He con- 
sidered it to consist of a suppuration of the lungs, 
which might be of an acute or chronic nature; that 
it resulted from mucus, blood or other morbid prod- 
ucts in the lungs or pleural cavity, which failing 
to be absorbed was changed into purulent matter. 
He thus describes the course of " phthisis " : 



THE HISTORY OF TUBERCULOSIS 23 

" With many persons," he says, " it commenced 
during the winter, and of these some were confined 
to bed, and others bore up on foot; the most of 
these died early in the spring who were confined to 
bed; of the others the cough left not a single person, 
... in the greater number of cases the disease 
was long protracted." In his aphorisms he says: 
" Phthisis most commonly occurs between the ages 
of 18 and 35." 

" In persons who cough frothy blood, the dis- 
charge of it comes from the lungs." 

" Diarrhoea attacking a person afflicted with 
phthisis is a mortal symptom." (Adams' trans- 
lation.) 

Hippocrates recommended tar as a remedy, sug- 
gestive of the modern creosote treatment. 

Isocrates, a contemporary of Hippocrates, con- 
sidered pulmonary phthisis to be a contagious 
disease, — a keen observer. 

In the first century of the Christian era (50 
a. d.) Aretseus Cappadox, a celebrated Greek phys- 
ician, wrote very intelligently of the disease and 
was the first to clearly describe pulmonary tuber- 
culosis, or phthisis, as it was then called, as a definite 
pathological process. He considered it to be 
caused by abscess of the lungs, chronic bronchitis 
or pulmonary hemorrhage from which pus might 
be formed in the lungs. For treatment he recom- 
mended sea voyages and the use of milk and eggs. 
Celsus, a Roman contemporary of Aretseus, held 
that there were three forms of consumption : (a) 



24 PULMONARY TUBERCULOSIS 

an atrophy of the lungs; (b) cachexia; (c) ulcer- 
ation of the lungs. He advised the use of mutton 
suet boiled in flour. 

Galen (130 a. d.), the most eminent physician 
after Hippocrates, held views as to the pathology 
of the disease similar to those of his great pre- 
decessor. He considered it to be an ulceration or 
suppuration of the lungs; the destroyed portions 
being discharged in the expectoration. This con- 
dition he compared with ulceration of other organs, 
as of the stomach, bladder, etc. In his opinion the 
disease was due to irritation or injury of the lung 
tissue followed by hemorrhage, although he recog- 
nized that ulceration of the lung might occur with- 
out hemorrhage, caused by corrupt secretions. 
When the disease occurred in this way, he consid- 
ered it incurable. He also mentions its infectious 
nature. He recommended the same treatment as 
had been found successful in treating ulcers in other 
organs, namely, such measures as would dry up 
secretions ; hence, he used to send his consumptive 
patients to dry, elevated resorts. He also advised 
a milk diet. 

After Galen, a long period elapsed before any 
advance was made in the knowledge of phthisis. 
Indeed, it was not until the middle of the seven- 
teenth century, when practical anatomy began to 
be studied — the " Anatomical Period " — that 
there was any notable advance in the knowledge of 
the disease. 

Sylvius (16 14-1672) was the first to accurately 



THE HISTORY OF TUBERCULOSIS 25 

describe tubercles of the lungs. In his " Tractus 
de Phthise " he attributes the ulceration of the lungs 
to the suppuration of tubercles which in softening 
finally^ produced cavities. He believed that there 
were two varieties of pulmonary phthisis: the one 
due to purulent infiltration of the lungs (the Hip- 
pocratic and Galenic theory) caused by hemoptysis, 
or empyema, and characterized by ulceration, sup- 
puration and destruction of lung substance ; and that 
the other variety was the result of a scrofulous con- 
stitution due to enlarged lymph glands or nodes in 
the lungs which suppurated, softened and were con- 
verted into tubercles. 

Richard Morton (1689), an English physician, 
was the most important investigator after Sylvius, 
and in his celebrated work on " Phthisiology " he 
emphasizes the tubercle as the true cause of the 
disease and that phthisis was always dependent 
upon it. Like Sylvius he also noted the relation 
between phthisis and scrofula. Morton was the 
first who maintained that the tubercle was a neces- 
sary antecedent to ulceration. Morton recognized 
the great prevalence of consumption, and in the 
following quotation he seems to have truly divined 
what we all now believe, that almost every adult 
has some tuberculous infection. He says : " Yes, 
when I consider with myself how often in one year 
there is cause enough ministered for producing 
these swellings, even to those that are wont to ob- 
serve the strictest rules of living, I cannot suf- 
ficiently admire that any one, at least after he comes 



26 PULMONARY TUBERCULOSIS 

to the flower of his youth, can dye without a touch 
of consumption." 

As time went on, many other eminent investi- 
gators, as Sydenham (1624- 1669), Boorhaave 
(1668-1738), Swieten (1700-1732), Morgagni 
(1682-1771), Auenbrugger (1722-1809) (the dis- 
coverer of percussion) wrote upon phthisis but giv- 
ing essentially the same views as their predecessors. 

The next most important advance in the pathol- 
ogy of phthisis was made by Matthew Baillie in 
1793, who, in a small treatise entitled " The Mor- 
bid Anatomy of the Most Important Parts of the 
Human Body," describes as the most frequent 
lesion in the diseased lung the presence of small 
nodes, at first about the size of the head of a pin, 
which later coalesce and increase in size. These 
nodes breaking down and suppurating he regarded 
as the cause of consumption. Baillie appeared to 
make a distinction between scrofulous glands and 
the nodes or tubercles, although he held that they 
both possessed the common property of being 
changed into caseous matter. 

Bayle (1774-1816) may be considered the 
founder of the modern pathology of pulmonary 
tuberculosis. He started with the miliary tubercle 
and described its development from the solid con- 
dition to the stage of caseation and softening. 
Since tubercles occurred in other organs of the 
body, he concluded that phthisis was not a disease 
confined to the lungs alone. He considered it a 
general disease of a specific nature, and not a local 



THE HISTORY OF TUBERCULOSIS 27 

one, caused by inflammation of the glands or lym- 
phatic system. He believed that hemoptysis was a 
result and not a cause of tuberculosis. He made 
six types or forms of phthisis, namely : 

(a) Tuberculous phthisis. 

(b) Granular phthisis. 

(c) Phthisis with melanosis. 

(d) Ulcerative phthisis. 

(e) Calculous phthisis. 

(f) Cancerous phthisis. 

Laennec (1781), the inventor of the stethoscope 
and the discoverer of mediate auscultation, main- 
tained that there was but one species of phthisis, 
namely, the tuberculous, and he considered phthisis 
and tuberculosis of the lungs as identical, both hav- 
ing their origin in the miliary tubercle. This was 
called the "Unity Theory." Louis (1827), the 
great French physician and successor of Laennec, 
also agreed with his predecessor and adopted his 
views. 

With Laennec and his school the period of open- 
eyed observation closed and that of histological in- 
vestigation followed. 

Virchow (1850), an eminent German pathologist 
and the founder of the so-called " cellular pathol- 
ogy," was the father of the " dualistic theory," 
which was that there were two kinds of phthisis : — 

(a) Tuberculous phthisis. 

(b) Caseous pneumonia. 

Virchow also held that caseation was a general 



28 PULMONARY TUBERCULOSIS 

pathological change met with in many morbid 
products and not peculiar to tubercle. 

Niemeyer (1866), a distinguished follower of 
Virchow, strenuously sustained his master's theory, 
and thought that the worst fate that could befall 
a consumptive was to become tuberculous. For 
many years Niemeyer's text book upon general 
medicine was the standard one in the medical 
schools, and so the dualistic theory was generally 
taught and accepted. 

We come now, finally, to the period of experi- 
mental investigation. 

Klencke (1843) produced tuberculosis in rabbits 
by injecting into their jugular veins tubercle cells 
taken from miliary tubercles and from tubercles in 
the stage of gray infiltration. It is doubtful if he 
himself fully appreciated the importance of his dis- 
covery. However it may be, his work was for- 
gotten and had no influence upon the existing theory 
of tuberculosis. 

Villemin (1865), a French army surgeon, re- 
peated on a far more extensive scale, the experi- 
ments of Klencke. He inoculated rabbits with 
matter and sputum from tuberculous individuals 
and also from the tuberculous tissue of a cow. In 
every case he produced tubercles in the lungs. 
When he injected animals with pus, however, no 
tuberculosis resulted. Villemin's paper presenting 
his experiments and their results, published in 1865, 
may be classed with Koch's later contribution upon 
the discovery of the tubercle bacillus, as great 



THE HISTORY OF TUBERCULOSIS 29 

epochal contributions to scientific medicine. Vil- 
lemin, however, did not escape the lot which befalls 
most discoverers of new things in medicine. His 
conclusions were so novel and so at variance with 
the accepted ideas of the time that they did not 
receive universal acceptance. Furthermore, some 
authorities thought that his experiments were faulty 
and hence his conclusions were to be doubted. 

Conheim, however, in 1877 repeated and ampli- 
fied Villemin's experiments. He injected tuber- 
culous matter into the anterior chamber of the eye 
of a rabbit and thus by ocular proof demonstrated 
the fact of the inoculability of tuberculosis, for he 
saw the gradual development of the specific 
tubercle. 

Other investigators corroborated these experi- 
ments of Villemin and Conheim. Thus, finally, 
that which had been suspected or believed to be 
true — that tuberculosis was communicable — for 
so many years, nay, centuries, became a demon- 
strated fact. Isocrates, six centuries before Christ, 
believed tuberculosis to be contagious, as we have 
seen, and in 1638 Lazarus Riverius, in his " Prac- 
tice of Physik," one of the chief works of medicine 
of his time, thus wrote : " Moreover there are 
causes of pulmonary phthisis, as contagion, which 
is chiefest, for this disease is so infectious that we 
may observe women to be infected by their hus- 
bands and men by their wives and all their children 
to die of the same, not only by heredity but from 
the company of him who was first affected." 



30 PULMONARY TUBERCULOSIS 

In 1754 Florence enacted sanitary laws regarding 
tuberculosis and in 1782 Naples did likewise, isolat- 
ing consumptives and destroying their belongings. 
In 1760 a special hospital was erected in Olibuzza 
for the isolation of consumptives to which they 
were removed from other hospitals. In Spain and 
Portugal similar precautions were taken. Physi- 
cians in Italy who did not report their cases of 
consumption were fined 300 ducats (between $600 
and $700) for the first offense and for the second 
were exiled for ten years. Rather a more serious 
penalty for failing to report cases of the disease 
than that existing to-day. Physicians who refused 
to send their consumptive patients to the special 
hospital for such cases, or removed them without 
the knowledge of the officers of health, were given 
three months' imprisonment, if of low birth, or 
fined 300 ducats, if of noble birth. 

Thus, after long years of observation, patient 
investigation and experiment, it was definitely 
established that consumption always took its origin 
in the tubercle and that it was communicable or in- 
fectious. The next step was to determine how the 
infection took place, what caused the tubercle? 
Was it a specific micro-organism which entered the 
body from the outside? Pasteur's remarkable re- 
searches upon the bacterial origin of diseases and 
those of Tyndall's upon " Floating Matter of the 
Air in Relation to Putrefaction and Infection " sug- 
gested this. So the investigations and discoveries 
in one department of science all unconsciously aid 



THE HISTORY OF TUBERCULOSIS 31 

in the solution of problems in another scientific 
domain. 

Robert Koch (frontispiece), a German physi- 
cian in a country town, conceived the idea that 
it was a specific " contagium vivum " which 
entered the body and set up the mechanism of the 
tubercle formation, and he set about to see if he 
could prove it. At about this time the new science 
of bacteriology and the method of differential stain- 
ing was beginning to be developed, and the com- 
pound microscope had been improved and perfected 
and the Abbe condenser added. With this idea in 
mind of a specific micro-organism as the cause of 
tuberculosis, and with the new tools of bacteriology, 
staining, and the improved microscope, Koch set to 
work, and after long, patient labor and many fail- 
ures, he succeeded in demonstrating in the tuber- 
cles of recently killed animals the rod-like micro- 
scopic structure which we know now as the tubercle 
bacillus. He invariably found these micro-organ- 
isms in all tuberculous tissues, in the lungs, scrof- 
ulous glands, tuberculosis of the bones and joints ; in 
lupus in the sputum of consumptives and in tuber- 
culous cattle; in brief, in all diseases which from 
their nature and structure could be considered as 
tuberculous. 

The next point to be determined was whether 
this tubercle bacillus was the sole and invariable 
cause of tuberculosis. Was this constantly recur- 
ring bacillus an actual, independent organism, or 
was it the product of disintegrating tissue? To 



32 PULMONARY TUBERCULOSIS 

prove this point Koch saw that he must obtain a 
pure culture of the bacillus and inoculate animals 
with it and see if tuberculosis ensued. After in- 
finite pains and patience Koch succeeded in cultivat- 
ing a pure crop of the tubercle bacilli upon a me- 
dium of blood serum. Now came the crucical step 
in the investigation : would these pure cultures of 
the tubercle bacillus produce tuberculosis in well 
animals? One can well imagine the intense ex- 
pectancy of Koch as he proceeded to this last and 
deciding step in his experiment. He inoculated 
with his pure culture 217 animals, — 94 guinea-pigs, 
70 rabbits, 9 cats and 44 mice, and then with in- 
tense interest he awaited the result. His state of 
mind must have been similar to that of all great 
discoverers : Franklin with his kite and key in the 
thunder storm ; Morse with his telegraph ; Bell with 
the telephone; Marconi with wireless telegraphy. 
Not a single one of the animals inoculated escaped 
tuberculosis. At the same time Koch injected all 
kinds of diseased tissues into guinea-pigs and rab- 
bits and the result was always negative to tuber- 
culosis. 

Thus finally the truth regarding the true aetiology 
of tuberculosis was revealed, after centuries of ig- 
norance of its cause. By Koch's supreme achieve- 
ment tuberculosis is known to the world as an 
infectious disease, the sole cause of which is the 
tubercle bacillus. Little by little, as we have seen 
in the foregoing pages, our knowledge of the dis- 
ease increased and grew more definite through the 



THE HISTORY OF TUBERCULOSIS 33 

study of the many investigators through the years, 
until the final consummation came. 

So does " science move but slowly, 
Slowly creeping on from point to point." 

Koch issued an account of his discovery and its 
demonstration in 1882. As always with regard to 
any great discovery, some doubted his results, but 
no one was able to disprove them. As Osier has 
well said : " The enemy is known, its life history 
is known, the mode of entrance into the system is 
known, and this has been followed by the fourth 
stage in the history of the disease, the period of 
prevention." 



CHAPTER III 

PATHOLOGY AND BACTERIOLOGY 

" Diseases are often to be traced by visible changes of 
structure in the internal parts of the body. . . . They 
throw light upon what is past; they afford some guidance 
for the time to come." 

Thomas Watson. 

The tubercle bacillus is an infinitesimally small, 
slender rod, in length from one-quarter to one-half 
the diameter of a red blood corpuscle. It is fre- 
quently more or less curved, and sometimes has an 
irregular knobbed appearance. When once well 
recognized in its red color, its characteristic appear- 
ance can never be forgotten or mistaken. It may 
occur in chains or in small clumps. It is a para- 
site and does not multiply outside of the body, 
except when grown upon a favorable medium. It 
belongs to the class of acid fast or acid proof bacilli 
and its envelope is penetrated by stains with diffi- 
culty. Acids do not remove the stain. It is a long 
lived, tough parasite, and under favorable condi- 
tions may retain its vitality for several months. 
Hidden away in dark, damp corners, it lies in wait 
for its victim, or mounted upon particles of dust, 
it roams about ready to be inhaled by any one liv- 
ing in the dust-laden atmosphere. Floating on dust 
34 



PATHOLOGY AND BACTERIOLOGY 35 

in the air, the bacillus may retain its infectivity for 
eight or ten days. 

It is destroyed by sunlight in a few hours, and 
by diffuse daylight in twenty-four hours. Various 
germicides kill it ; for example, a five per cent, solu- 
tion of carbolic acid added to an equal volume of 
sputum will kill the bacilli in twenty- four hours. 
So will a two per cent, lysol solution, or a fifteen 
to twenty per cent, solution of formalin. An equal 
volume of the disinfecting solution must be used 
and thoroughly incorporated with the sputum. It 
must be borne in mind that when the tubercle bacilli 
are enclosed in mucus it requires a longer time to 
destroy them. Heat at a temperature of 150 to 
160 F. also kills the bacilli when moist in from 
ten to fifteen minutes. When dry, it requires a 
higher temperature for a longer time. In milk, a 
temperature of 140 to 167 F. continued for one 
hour is also effective. Pasteurized milk (heated 
to from 155 to 158 F. for twenty to thirty min- 
utes) can be considered safe. Cold to any degree 
has no destructive influence upon the bacillus. It 
will retain its vitality for a considerable time in 
decomposing animal tissues, and it has been found 
in the soil of sewage fields. The gastric juice, 
although it impedes its development, from its acid- 
ity, does not destroy it. It has been estimated from 
carefully obtained data that a consumptive may 
expectorate 500,000,000 to 3,000,000,000 tubercle 
bacilli in twenty-four hours. It is to be remem- 
bered that the dry bacilli retain their vitality for a 



36 PULMONARY TUBERCULOSIS 

long time, and hence the danger in a room where 
there is an unclean consumptive who allows his 
sputum to become dry and coughs in the air. 

Besides the human tubercle bacillus there is that 
of the bovine type which differs from the former 
in action and slightly in form. It is shorter, 
straighter, and thicker, and is more virulent for 
rabbits. Whether these two forms are distinct 
types or variations of a single type is a question 
still under discussion. Both produce tuberculosis 
in man and animals, although the human tubercle 
bacillus less readily infects cattle than that of the 
bovine type. 

The tuberculosis in children under five years of 
age in the form of tuberculous glands and abdom- 
inal tuberculosis has been found, in a certain num- 
ber of cases, to be due to the bovine tubercle bacilli 
ingested in milk. From the investigations of Park 
and others the conclusion has been reached that 
from six and one-half per cent, to ten per cent. 
of deaths of young children from tuberculosis are 
from bovine source through infected milk. The 
obvious lesson is to secure milk from cows proved 
to be non-tuberculous or to pasteurize it. 

Staining the Tubercle Bacillus 

The simplest and quickest method of staining the 
tubercle bacillus, and the one ordinarily employed, 
is that of the Ziehl-Nielsen, and the technique is 
as follows : The morning sputum is to be ob- 
tained if possible, and from it one of the grayish 



PATHOLOGY AND BACTERIOLOGY 37 

particles having the most consistency, and as being 
the most likely to contain the bacilli, is selected and 
thinly and evenly spread over a cover glass or slide. 
This is dried by passing the glass rapidly three times 
through or over the flame of a Bunsen burner or 
alcohol lamp; thus the material is fixed. Next, 
this is stained with the carbol-fuchsine solution 
which is composed of saturated alcohol solution 
of fuchsine 11 c.c, and solution of carbolic acid 
(five per cent.) 100 c.c. Sufficient stain is used to 
entirely cover the film. This is then held over the 
flame for from thirty seconds to one or two minutes 
until steam arises, not allowing it to become dry. 
Wash in water and decolorize with the acid solu- 
tion, which is composed of either nitric, hydrochloric 
or sulphuric acid in the proportion of five parts of 
concentrated nitric acid to 95 parts of alcohol (80 
per cent.), a three to five per cent, of hydrochloric 
acid in 80 or 90 per cent, of alcohol, or a twenty per 
cent, of sulphuric acid. The preparation is alter- 
nately put in the decolorizing fluid and washed until 
the red color disappears. After the final washing it 
is counter-stained with Loffler's methyline blue solu- 
tion, allowing the solution to remain on the glass 
for from thirty seconds to one minute. This is 
then washed off with water, the glass dried, 
mounted, and examined with the oil-immersion lens. 
It is evident that a specimen of sputum may con- 
tain tubercle bacilli and yet the particular particle 
examined may give a negative result ; and this is all 
the more likely to happen when there are but few 



38 PULMONARY TUBERCULOSIS 

bacilli in the whole specimen. In order to obviate 
so far as may be this possibility, two methods have 
been employed which have proved of much value, 
the object being to soften and concentrate the 
sputum and destroy other bacteria. These two 
methods are called (a) the antiformin and (b) the 
Ellerman and Erlandsen methods. 

The Antiformin Method 

Antiformin, which contains sodium hydroxide 
and sodium hypochlorite, is mixed with the speci- 
men of sputum in the proportion of one part of the 
fluid to five parts of the sputum. This is allowed 
to stand for three or four hours, long enough for 
the sputum to soften; it is then diluted with water 
or alcohol and centrifugalized; the sediment is col- 
lected and again centrifugalized once or twice more, 
when the final sediment is stained and examined in 
the usual way. 

The Ellerman and Erlander Method 

For the technique of this method I am indebted 
to Dr. H. M. King of the Loomis Sanatorium where 
it is in use. 

The entire expectoration of three days is col- 
lected in a clean wide mouth bottle. To this is 
added an equal volume of 0.6% sodium carbonate 
solution. After shaking, the mixture is placed in 
an incubator and allowed to digest at a temperature 
of 37 C. for twenty-four hours. The time of 
digestion should be increased with thick purulent 



PATHOLOGY AND BACTERIOLOGY 39 

specimens. The mixture is removed from the in- 
cubator, and should consist of two layers ; the upper 
cloudy fluid, the lower a varying amount of homo- 
geneous sediment. The entire fluid portion is 
poured off (into 5% lysol or similar solution), 
and to the remaining sediment is added four or five 
volumes of 0.25% sodium hydrate solution. The 
mixture is next transferred to a suitable vessel 
and boiled for one or two minutes. Large test 
tubes (eight by one inch) or small beakers are 
found convenient. After cooling, the mixture is 
transferred to 50 cc. centrifuge tubes and centri- 
fugated for ten or fifteen minutes at high speed. 
The resulting sediment is smeared upon two or 
three slides, making rather thick smears, and then 
stained in the usual manner. 

It is hardly necessary to add that when the 
sputum is examined in the ordinary way, a single 
negative result is not conclusive evidence that tuber- 
culosis does not exist if there are suspicious or 
definite symptoms and physical signs. Under such 
circumstances one would not infrequently be de- 
ceived if he rested content with a single negative 
examination. The sputum should be examined sev- 
eral times by the ordinary method, or by one of 
the two methods given above, before a definite con- 
clusion is made that the sputum is bacilli-free; and 
even then, if there are definite symptoms and signs 
not referable to other causes, a tentative diagnosis 
of tuberculosis should be made. 



40 PULMONARY TUBERCULOSIS 

Entrance of the Tubercle Bacillus into the Lungs 

The tubercle bacillus reaches the lungs in two 
principal ways: (a) directly through the respira- 
tory passages, by inhalation, and (b) indirectly by 
way of the gastro-intestinal canal, by ingestion. 
Which is the more frequent path is still a debatable 
question, but the weight of opinion seems to be in 
favor of the inhalation route. 

Action of the Tubercle Bacillus. History of the 
Tubercle 

When the tubercle bacilli have gained entrance 
into the lungs by one or the other route, they may 
be destroyed and leave no evidence of their visit, 
or they may produce certain inflammatory changes 
peculiar to their specific nature, just as other irri- 
tants or specific bacteria cause inflammatory phe- 
nomena peculiar to their specific influence. As 
with all forms of inflammation, we may have reso- 
lution, necrosis or ulceration, and a reparative 
tendency, as the formations of fibrous tissue. The 
tubercle bacillus by its irritant effect either gives 
rise to the formation of the characteristic tubercle, 
composed of epitheloid, lymphoid and generally 
giant cells with a reticulum of fibrous tissue; or else 
to a diffuse tuberculous infiltration with few if any 
distinct tuberculous nodules; or to a tuberculous 
exudative inflammation, as in tuberculous pneu- 
monia. 

Individual tubercles coalesce and form a nodule 



PATHOLOGY AND BACTERIOLOGY 41 

or conglomerate tubercle, and when a certain stage 
is reached in its development, degeneration or 
necrosis takes place in its center, of a specific form 
called caseation or softening. This caseation is 
one of the characteristics of all forms of tuberculous 
inflammation in the lungs. In acute tuberculosis 
this softening progresses uninterruptedly with little 
or no attempt at repair, but in the chronic form 
nature attempts to limit or strangle the tuberculous 
focus by fibrosis, the formation of connective tissue, 
and this is the way in which healing takes place. 
The tuberculous tissue or tubercle may be directly 
transformed into fibrous tissue, the most perfect 
form of healing, but this, unfortunately, does not 
often happen after the disease has become estab- 
lished. The caseous mass may become calcified to 
a greater or less extent, thus limiting its destructive 
influence, or it may be surrounded by a fibrous en- 
velope, encapsulated. Within this envelope, how- 
ever, there are often virulent tubercle bacilli, which 
may burst their bonds and produce further disease ; 
or the escaped bacilli may enter the blood stream 
and acute miliary tuberculosis ensue. 

Caseation and fibrosis do not usually go on sep- 
arately, but simultaneously, and the result depends 
upon which process finally becomes supreme. The 
formation of fibrous tissue generally takes place at 
one part of the tuberculous area, while the disease 
slowly spreads at another. When extensive case- 
ation or softening occurs, cavities are formed. In 
active tuberculosis the toxin of the tubercle bacillus 



42 PULMONARY TUBERCULOSIS 

produces, as in other infections, certain constitu- 
tional disturbances, such as fever, rapid pulse, loss 
of weight and strength, and other evidences of a 
systemic infection. 

In quiescent cases, however, we may have very 
extensive disease with little or no disturbance of 
the general health ; the individual may have the ap- 
pearance of perfect health, may be able to follow 
his usual mode of life, and feel as well as ever. 

The tubercle bacillus cannot be destroyed in situ, 
although many attempts have been made to do so. 
Likewise, innumerable attempts have been made to 
directly excite the formation of connective tissue, 
but none of the especial methods tried have been 
successful. The only hope of arresting the disease 
is to aid nature in her efforts to form fibrosis, and 
the only successful method of accomplishing this is 
the general plan of increasing and maintaining the 
general resistance of the individual by all the means 
included in the " open-air " treatment. 

Post Mortem Appearances of Tuberculous Lungs 

The changes seen in the lungs of one who has 
succumbed from tuberculosis are varied, depending 
upon the form and stage of the disease. In acute 
miliary tuberculosis, the lungs are studded with 
nodules of miliary tubercles, and there is general 
congestion. In acute tuberculous pneumonia, we 
have the characteristic exudative changes, as in 
non-tuberculous pneumonia, and, in addition, case- 
ation — softening — and the production of cavities. 




Fig. 7. " Both upper lobes contain cavities and large amounts 
of fibrous tissue. Section of left lung illustrated shows 
upper lobe converted almost entirely into fibrous tissue 
with several small cavities. Caseated tubercles in the 
lower lobe." 
From U. S. Army General Hospital, Fort Bayard, N. M. 



PATHOLOGY AND BACTERIOLOGY 43 

In the more common fibro-caseous form, we find 
tubercles or nodules, areas of inflammatory infiltra- 
tion or consolidation, with caseous — softening — 
ulceration, the formation of cavities, and the pro- 
duction of connective tissue — fibrosis — in the at- 
tempt to arrest or limit the disease. The longer 
the disease has existed and progressed, the greater 
the destructive changes, as indicated, for example, 
in huge cavities. (Fig. 7.) 

Mixed Infection 

The tuberculous lesions offer a favorable medium 
for other micro-organisms, and in more or less ad- 
vanced cases, various other pathogenic bacteria are 
frequently found, such as the streptococcus, pneu- 
mococcus, staphylococcus, and the influenza bacillus, 
in friendly companionship with the tubercle bac- 
illus. This alliance makes a bad matter worse and 
by their united toxic effect intensifies the symptoms. 
The fight then becomes one between the allied armies 
of the tubercle bacillus and the other pathogenic 
organisms, and the army of the resisting host. 

Extension of the Disease 

From the initial focus the tubercle bacilli may 
be carried to other parts of the lung or to other 
organs or portions of the body. Such migration 
may take place by the route of the blood, the lym- 
phatics, or by the natural channels which lead from 
the diseased focus to other parts of the organ or 
to the bronchi. 



44 PULMONARY TUBERCULOSIS 

Cavities and Fibrosis 

Softening, if continued, leads to the formation 
of cavities. Several cavities may occur in the same 
lung, and they may unite. If the resistance over- 
comes the infection, the cavities may cease to grow ; 
the destroyed material is eliminated and cicatricial 
tissue may form in the cavity walls — a reparative 
process. If this fibrosis predominates, we event- 
ually see the cavity filled with a thick fibroid mass, 
and contraction takes place. The predominance of 
the fibroid process may exist from the first and 
form the characteristic feature of the disease. 
When this happens, the progress of the disease is 
slow and the constitutional symptoms comparatively 
slight, dyspnoea being the most prominent symp- 
tom. When fibrosis is the chief pathological fea- 
ture, the name fibroid phthisis or fibroid tuberculo- 
sis is given to the disease. 

True Healing 

Genuine healing can only be said to have occurred 
when all caseous material is destroyed and calci- 
fied deposits or connective tissue replaces it. The 
healed focus then has the appearance of a puckered 
cicatrix. Encapsulation of the caseous mass is not 
true healing, though it is an arrest of the disease, 
for living tubercle bacilli may be contained within 
the encapsulating envelope. 

Cause of Hemorrhage 

The slight or moderate hemorrhages which occur 
in one-half or more of all cases of pulmonary tuber- 



PATHOLOGY AND BACTERIOLOGY 45 

culosis, generally result from the rupture, through 
ulceration, of a small vessel in the diseased area, or 
from exudation. Extensive and often fatal hemor- 
rhages are generally caused by the rupture of an 
aneurysmal enlargement of a vessel projecting into 
a cavity. 

Infection and Period of Incubation 

How long after the implantation of the tubercle 
bacillus acute manifestations of the disease occur, 
we do not know. We know, however, that the de- 
velopment of the infection is generally slow ; months 
or years may elapse before active symptoms ap- 
pear, or they may never occur. We believe also that 
infection is not caused by a transitory exposure to 
the bacillus, but by a continuous and oft-repeated 
one. Hence we call tuberculosis a house disease, 
for in the house where there is one individual suf- 
fering from the disease, others who are constantly 
associated with him are more likely to become in- 
fected, as investigation and experience have shown. 

Predisposition: Acquired; Inherited 

(a) Acquired: 

Not every one, however long he may be exposed 
to the tubercle bacillus, becomes actively infected. 
In order that this may happen, one must have an 
inherited or acquired predisposition. We can only 
guess as to. what causes this predisposition or re- 
ceptive state. In general one can predicate that 
whatever influence, long-acting, which lowers the 



46 PULMONARY TUBERCULOSIS 

normal resistance, produces a favorable soil for the 
bacillus, an acquired predisposition. Such influ- 
ences are legion : unwholesome conditions of living 
and working, dusty occupations, lack of sunlight 
and fresh air, over-fatigue, under-feeding, insuffi- 
cient rest and sleep, are some of the chief of these 
influences. Certain diseases, as recurrent bronchi- 
tis, measles, whooping cough, the " grippe," dia- 
betes, also appear to be predisposing influences. As 
the majority of adults have some tuberculous in- 
fection, and yet so many escape the active disease, 
it is evident that the difference in individuals as to 
their susceptibility depends upon the resistance of 
their tissues rather than upon their resistance to 
infection, 
(b) Inherited: 

What part inheritance plays in the receptivity of 
the organism we cannot say. Of course, the old 
idea of the direct inheritance of the disease is no 
longer tenable in the light of our present knowledge 
of its infective nature. The frequency, however, 
with which tuberculosis occurs in those of tuber- 
culous parentage would seem to indicate the prob- 
ability of an inherited susceptibility. Nevertheless, 
this is by no means certain, and it may only mean 
that a weakened body is inherited from those de- 
bilitated by a wasting disease, like tuberculosis, and 
hence the organism is less resistant to tuberculous 
infection, to which it is more likely to be exposed 
than to any other infection. " It seems perfectly 



PATHOLOGY AND BACTERIOLOGY 47 

plain," says Davenport 1 considering the question 
from an eugenic standpoint, " that death from 
tuberculosis is the result of infection added to nat- 
ural and acquired non-resistance." 

Acute Tuberculosis 

Generally in speaking of pulmonary tuberculosis, 
one refers to the chronic fibro-caseous form; but, 
as in all inflammatory conditions, we have also acute 
tuberculosis in which the caseous element practically 
alone exists, and the disease is purely destructive 
and acute from start to finish. There is no re- 
sistance on the part of the organism and the infec- 
tion has its own way without hindrance. We have 
the lobar-pneumonic and the broncho-pneumonic 
forms. Acute miliary tuberculosis stands rather in 
a class by itself. 

Acute Miliary Tuberculosis 

Acute miliary tuberculosis is always a secondary 
infection from a pre-existing tuberculous focus 
somewhere in the body, from which there is an erup- 
tion of tubercle bacilli into the blood stream which 
carries them to the various organs of the body. 
This untoward event may happen as the terminal 
stage of a chronic tuberculosis, or may occur in an 
individual in which the original disease appeared 
to have been arrested or was in a quiescent condi- 
tion. 

1 " Heredity in Relation to Eugenics," by Charles Benedict 
Davenport, New York, 1913. 



48 PULMONARY TUBERCULOSIS 

It is often quite impossible to make a diagnosis 
of acute miliary tuberculosis, the physical signs are 
so indeterminate. It resembles typhoid fever and 
can be mistaken for it. It also simulates acute 
bronchitis of the smaller tubes. One should seek 
for evidence of tuberculosis in other parts of the 
body. The marked discrepancy between the phy- 
sical signs and the symptoms of extreme dyspnoea, 
cyanosis, great prostration, and the lower and less 
continuous temperature with the one distinctive phy- 
sical sign of fine, moist rales throughout the chest, 
heard perhaps only after cough, are the most im- 
portant guides to diagnosis. 

It is always acute and almost invariably fatal. 
It is the overwhelming toxic influence of the bacilli 
which produces the profound depression and the 
fatal issue. It is the drive of a victorious invading 
army overcoming all resistance. It runs its course 
in from a few days to a few weeks. 

The treatment can only be symptomatic. An ex- 
ample : — A patient came to my clinic upon Tues- 
day with great prostration and fever. Upon phy- 
sical examination only fine, moist rales were found 
in his chest. He was referred to the hospital where 
he died on the following Friday. The autopsy re- 
vealed general acute miliary tuberculosis. For- 
tunately, this dire form of tuberculosis is not com- 
mon, but in cases resembling typhoid fever, when 
the Widal reaction is negative, and other signs of 
the disease are absent, acute miliary tuberculosis 
should be borne in mind. 



PATHOLOGY AND BACTERIOLOGY 49 

Acute Lobar-pneumonic Tuberculosis 

In this form of acute tuberculosis the general 
symptoms and physical signs so nearly simulate or- 
dinary lobar-pneumonia that in the early stages it is 
quite impossible to make a differential diagnosis 
unless, fortunately, tubercle bacilli are detected in 
the sputum, which, however, is rarely the case in the 
early stage of the disease. One becomes suspicious 
when resolution does not occur at the usual time; 
but even then the case may be regarded as one of 
delayed resolution. As time goes on, however, the 
real nature of the disease becomes revealed. The 
fever continues; flesh and strength rapidly fail; the 
expectoration becomes more profuse and purulent; 
and spots of softening in the consolidated lung fol- 
lowed by the formation of cavities are detected. 
Tubercle bacilli will be found in the sputum, if they 
have not appeared before. The disease may pro- 
ceed steadily on without remission, and the fatal 
end come in a few weeks. On the other hand, the 
severer symptoms may abate and the case become 
subacute and be prolonged for from two to six 
months. In every case of pneumonia one should 
always bear in mind the possibility of tuberculosis. 

Acute Broncho-pneumonic Tuberculosis 

This is the more common form of acute tuber- 
culosis and is the one to which the name of " gallop- 
ing consumption " has been given on account of the 
rapidity of its course. The clinical picture is quite 



50 PULMONARY TUBERCULOSIS 

different from that of the previous form, but the 
diagnosis in the early stage is equally difficult. The 
symptoms are not as pronounced or severe as in the 
lobar form. 

It is very common in childhood and youth, fol- 
lowing measles and whooping cough, or as a com- 
plication of " grippe," typhoid fever and diabetes. 
It may also follow hemoptysis. The symptoms 
and physical signs are at first those of an ordinary 
broncho-pneumonia. In the beginning it may re- 
semble an attack of " grippe." The advance is 
rapid. Soon we find areas of consolidation with 
moist rales, shortly followed by softening and the 
appearance of tubercle bacilli in the purulent ex- 
pectoration. The symptoms are marked and mark- 
edly out of proportion to the physical signs, which 
is a diagnostic point. There is rapid emaciation; 
extreme prostration; night sweats; dyspnoea, an- 
orexia, severe cough and continued high fever. The 
course of the disease is generally from two to six 
months, or it may be only a matter of weeks. The 
end generally comes from exhaustion, or meningitis, 
or hemorrhage may hasten it. As in the previous 
form, the acute symptoms may practically subside, 
and a more or less chronic stage supervene, but re- 
covery is very rare. 

Age Period and Resistance 

As with most other infectious diseases, pulmo- 
nary tuberculosis occurs most frequently in youth 
and early adult life, the most common age period 



PATHOLOGY AND BACTERIOLOGY 51 

being from fifteen to thirty-five or forty years of 
age, although no age is exempt from it. Infants 
and young children show the least resistance, and 
in later life, after fifty years of age, the resistance 
is again lowered, although the disease at this age 
period has a tendency to be very chronic. The re- 
sistance is greatest between twenty-five and fifty 
years of age. 

The Common Form of Tuberculosis 

The chronic or fibro-caseous form of pulmonary 
tuberculosis is the most common one and is that 
with which we shall hereafter have to deal. It is 
the type to which we commonly apply the term 
" consumption." As the name " fibro-caseous " in- 
dicates, the two processes, caseation — destruction, 
— and fibrosis — repair, healing — go on together. 
The opposing foes, the infection and the resistance, 
haye entrenched themselves for a long war. Many 
sallies take place from one or the other side; and 
as one or the other opposing forces holds the ground 
taken and steadily advances, so the final issue will 
be determined. If the tissues of the body are able 
to restrict and limit the growth of the bacilli and 
their advance into new country, and overcome the 
baleful effects of the toxins, then victory is assured 
and the disease arrested. All treatment can do is 
to equip the resistant powers of the body to do their 
best work. Treatment furnishes the munitions ; re- 
sistance must use them. 



CHAPTER IV 

DIAGNOSIS 

" Find out the cause of this effect." 
" Or rather say the cause of this defect." 
" For this effect defective comes by cause." 

Hamlet. Act II. Sc. 2 
" The physician ought in the first place to endeavor to 
ascertain the nature and state of the disease by the com- 
mon symptoms alone." 

John Forbes. 

Early Diagnosis 

The early diagnosis of clinical or active pulmon- 
ary tuberculosis is easy or hard very much as one 
goes about it. Generally, I believe, the physician 
will be able to make a definite or probable diagnosis 
if he diligently studies his patient's condition in a 
methodical manner, correlating and combining the 
symptoms and carefully weighing their evidence. 
He must ever bear in mind that the symptoms usu- 
ally reveal more than do the physical signs, which 
are so often indefinite. If at the first examination 
he is unable to arrive at a conclusion, he can keep 
the patient under observation and subsequent ex- 
aminations may resolve the doubt. 
52 



DIAGNOSIS 53 

Suspicious Symptoms 

What are the indications which would lead one to 
suspect tuberculosis? There are a number of sus- 
picious symptoms, any one or several of which sug- 
gest it : 

(a) A persistent cough, which may be and often 
is so slight — perhaps occurring only in the morn- 
ing — that it is not admitted by the patient except 
upon careful questioning. " When there is a long 
persistent and otherwise unexplained cough," says 
Wilson, " accompanied by either a subnormal tem- 
perature or one that rises slightly in the afternoon 
a probable diagnosis of tuberculosis should be 
made." 

(b) A loss of bodily vigor or strength; one be- 
comes more easily fatigued than was his wont; as 
the patient often expresses it, he has " lost his 
courage," — • he doesn't feel up to his work. 

(c) A loss of weight which may be so slight that 
the patient is unaware of it until the scales prove 
it. 

(d) A slight and persistent rise of temperature 
in the afternoon. 

(e) A rapid pulse persistently above the normal 
in frequency, not always present, however, but gen- 
erally so in active tuberculosis. 

(f) Slight shortness of breath on exertion. 

(g) Loss of appetite not infrequently accom- 
panied by digestive disturbances. 

(h) Pain in the chest, frequently the only symp- 
tom which brings the patient to the physician. I 



54 PULMONARY TUBERCULOSIS 

have not found this symptom of much importance 
in indicating any tuberculous lesion, but it should 
always be followed up by a careful examination. 
Says Norris : " There are four easily ascertained 
and highly suggestive symptoms, the existence of 
which should always arouse our suspicion, unless 
their presence can be explained upon other grounds. 
They are: (i) rapid pulse; (2) evening rise of 
temperature; (3) loss of weight; (4) cough"; and 
I would add a fifth, namely, loss of strength. " The 
protracted existence of any two of these symptoms," 
continues Norris, " requires a good cause to be 
shown why the diagnosis of pulmonary tuberculosis 
should not be made." 

" Always say three things," says Gee, " to a pa- 
tient whom you suspect to be tuberculous " : 

( 1 ) " Get yourself weighed, by the same ma- 
chine each time, to see if you are losing weight." 

(2) " Use a thermometer two or three times each 
evening to see if there is any fever." 

(3) "Save your sputa to be tested (for bac- 
illi)." 

Hemoptysis is a symptom which almost invariably 
brings the patient to the physician, for there is noth- 
ing that alarms him more. It may be slight, only 
" streaked sputum," or it may be a mouthful or 
more. It is the nearest approach to a pathogno- 
monic symptom, and unless a definite source in 
the upper respiratory tract is discovered, or a car- 
diac lesion is found, it should be taken to mean 



DIAGNOSIS 55 

pulmonary tuberculosis even if no physical signs 
are detected and the patient otherwise appears to be 
in good health. For example: — A student came 
to me with the history of a slight hemoptysis after 
some unusual exertion. He had no other symp- 
toms, and, so far as he knew, was perfectly well. 
There were no abnormal physical signs. He con- 
tinued in his work and no other symptoms developed. 
Six months later he had another similar experience, 
again from some unusual exertion, and again there 
were no other symptoms or signs. An X-ray pic- 
ture, however, was taken which showed a small spot 
in one lung. He was sent to a sanatorium and later 
discharged with the report that they could find noth- 
ing the matter with him. 

There are various other slight suggestive symp- 
toms which should demand an examination of the 
lungs, for, as Lawrason Brown well says, " in few 
other serious diseases do we have to depend so 
much upon slight symptoms for early diagnosis." 
Such other symptoms are ( i ) chilliness, complained 
of after some slight exposure to cold or wet or a 
draft of air; (2) undue nervousness, which is often 
considered only a neurasthenic symptom; (3) pain 
and stiffness in the joints; (4) in women amenor- 
rhcea, although this does not usually occur in the in- 
cipient stages; (5) sweating after slight exertion; 
(6) anaemia; (7) recurring colds ; (8) persistent or 
intermittent hoarseness; (9) various digestive dis- 
turbances: Fistula-in-ano is a tell-tale symptom, 



56 PULMONARY TUBERCULOSIS 

and the diagnosis of malaria has been made, whereas 
the supposed malarial symptoms were really those 
of the toxaemia of an active tuberculosis. 

Sometimes one may come for an examination of 
the lungs, as many do now, presenting no evidence 
that the disease exists, but merely to see if he is 
" all right." Having determined then, for one 
reason or another, to make an examination of the 
person as to tuberculosis, the first step is to obtain 
the history, past and present, and follow up all 
clues. For the sake of method and thoroughness, 
a definite plan or scheme should be followed in do- 
ing this, and there are many such excellent outlines. 
Some have the fault, in my opinion, of being too 
redundant. My own is as follows : 

Scheme of Examination 

Name 

Date Residence 

Age M. S. W. Occupation Race 

Family History 

Exposure to Infection 

Past History 

Habits Venereal Alcohol 

Tobacco 

Present Illness : date and mode of onset. What definite 
thing does the patient complain of? 

Cough Appetite 

Expectoration Digestion 

Loss of Weight ; of Strength Pain 

Dyspnoea Ability to work 

Night Sweats Menstruation 

Hemoptysis Fever 

A routine procedure in the examination is of ob- 
vious advantage in eliciting certain definite facts 



DIAGNOSIS 57 

bearing upon a possible tuberculosis, but at the same 
time the patient should always be allowed to tell his 
own story in his own way which will not infrequently 
bring out important evidence not obtained by the 
questionnaire. Every circumstance in the patient's 
life, however unimportant it may seem in itself may, 
when taken with other evidence, aid in the diagno- 
sis; the name even, indicating the nationality, may 
suggest the conditions under which the patient has 
previously lived. So may the age, residence and 
domestic relations have a bearing upon both diagno- 
sis and prognosis. 

Occupation 

The occupation is significant. Is it an indoor or 
outdoor one? Is it pursued under a favorable or 
unfavorable environment? Is it, for example, a 
dusty occupation? For the incidence of tuberculo- 
sis is materially greater in dusty occupations, es- 
pecially where the dust, is metallic or mineral. Is 
it an occupation which requires excessive mental or 
physical demands and close confinement? One 
which does not allow proper time or opportunity 
for meals, rest, fresh air and recreation? 

Family History 

If there is a history of tuberculosis on the pater- 
nal or maternal sides indicating a possible inherited 
predisposition, it is a help; but if negative it is of 
little importance. The family history, however, if 
one has time to follow it up, and the patient knows 



58 PULMONARY TUBERCULOSIS 

it, will tell us something of the vigor, longevity and 
tendencies of the family stock. Some families are 
apparently inclined to certain weaknesses, or dis- 
eases, such as bronchitis, digestive disturbances, an 
unstable nervous system, rheumatism, etc., we can 
also learn something of the mental and physical 
traits the patient has inherited or what defects have 
been handed down to him. 

Exposure to Infection 

A history of exposure to a tuberculous infection, 
long continued and close, as from a case in the 
family, is of far greater importance than the fact 
of family inheritance, " than the fact," as Brown 
says, " that the forebear of the patient, one whom 
he has never seen, has had or died of tuberculosis" ; 
for investigation has shown that when one case of 
tuberculosis exists in the family, it is more than 
likely that other members of the same family may 
acquire the infection. Not infrequently, also, pro- 
longed and intimate association with an active 
tuberculous individual in workshop, factory or of- 
fice has led to the communication of the disease 
from the infected person to the well ; for example, 
a young woman, suffering from tuberculosis, a sec- 
retary in an office, was undoubtedly infected by 
her tuberculous employer who was careless in the 
disposal of his sputum. 

Past History 

Under this head, we may learn little or much, 
depending upon the inquisitiveness of the physician 



DIAGNOSIS 59 

and the responsiveness and intelligence of the pa- 
tient. What we desire to learn is the life history 
of the patient in childhood and adult life up to the 
time of examination. We wish to know what chil- 
dren's diseases he had, particularly measles and 
whooping cough, for there is evidence to show that 
these two infections render the lungs more sus- 
ceptible to a tuberculous infection. Was he a vigor- 
ous or sickly child? What was his environment 
and nurture in childhood and youth? In adult life 
did he suffer from any serious disease, such as 
typhoid fever, which sometimes is not typhoid fever 
at all but the awakening into activity of a latent 
tuberculous infection which again subsides? Such, 
also, may have been the real nature of a supposed 
attack of influenza. Has he ever had pleurisy, 
which, as we know, is secondary to a tuberculous 
infection in a large number of cases? Other sug- 
gestive diseases are recurring bronchitis, broncho- 
pneumonia, diabetes, and neurasthenia. One should 
also inquire into the past or present existence of 
syphilis which is sometimes associated with tuber- 
culosis and is a predisposing cause thereto, and is 
also sometimes mistaken for the latter disease. If 
any doubt exists a Wassermann test should be made. 

Habits 

From this inquiry, we learn the patient's routine 
of life, and whatever excesses he may have in- 
dulged in, although he will generally seek to mini- 
mize any bad habits in order to make out a good 



60 PULMONARY TUBERCULOSIS 

story. The use of alcohol, either habitually or 
spasmodically, is an important question to determine, 
for, as some one has said, " alcohol makes the bed 
of the consumptive," and its constant employment 
undoubtedly lowers the resistance; moreover, it is 
likely to interfere with proper and regular taking 
of food. As to tobacco, I have never been able to 
determine that it has any special influence as a 
causative factor, unless used in excess, or the smoke 
is inhaled, as with cigarette smoking. I have never 
seen a moderate use of tobacco with patients ac- 
customed to it do harm unless there was some special 
contraindication. 

Present Illness 

Under this head we seek to learn what symptom 
the patient first noticed which suggested to him the 
possibility of tuberculosis and when this first oc- 
curred. Hawes * thinks it better to ask the patient 
when he last felt perfectly well rather than when he 
first felt sick. As to the first symptom observed — 
the patient will generally give one or more of those 
enumerated in the beginning of the chapter which 
may here be repeated: (a) A persistent cough or 
cold with a little expectoration; (b) loss of weight; 
(c) loss of strength or nervous energy; (d) slight 
dyspnoea on exertion; (e) hemoptysis, generally 
slight; (f) chilliness followed by flushing or a feel- 
ing of undue warmth, indicative of fever; (g) pain 
in the chest, or pain referred to the shoulder blade ; 

i" Early Pulmonary Tuberculosis," J. B. Hawes 2d, Wm. 
Wood & Co., New York, 1913- 



DIAGNOSIS 61 

(h) hoarseness; (i) loss of appetite with digestive 
disturbances, all of which are specifically inquired 
into by the air of the questionnaire in the scheme. 

Of all the symptoms, I agree with Hawes, that 
there is no more common one than " loss of ambi- 
tion or energy." As one patient expressed it, he 
had lost all his " ginger." Again, the patient will 
date the beginning of his trouble from an attack 
of influenza, bronchitis, pleurisy or pneumonia. 
One must be sure that correct answers are obtained 
from the specific questions; for example, the pa- 
tient may at first say that he has no cough or ex- 
pectoration, but on careful inquiry we may elicit the 
fact that he has to " clear his throat " in the morn- 
ing and raises a " little ball of sputum " ; and in the 
" ability to work " he may not feel able to work, but 
yet is working from necessity. 

While obtaining the history as outlined above, 
the keen physician will have learned much about 
the general character and physical condition of his 
patient by carefully observing his general appear- 
ance, actions, nervous condition, manner of answer- 
ing questions, etc. 

Importance of Symptoms 

In early cases of pulmonary tuberculosis, one can- 
not be too painstaking in eliciting and studying the 
symptoms; for upon them we shall have to depend 
largely and sometimes entirely for our diagnosis. 
It must always be remembered that " symptoms fre- 
quently appear when no physical signs can be de- 
tected in the lungs." To depend upon indefinite, 



62 



PULMONARY TUBERCULOSIS 



doubtful physical signs to the neglect of a careful 
study of the symptoms will often lead to an errone- 
ous diagnosis. On the other hand also, remember 
that physical signs without symptoms mean only 
that there is a tuberculous infection and not active 
clinical tuberculosis, and therefore, because physical 
signs are detected and there is no other evidence 
that the patient is ill, he should not be removed from 
his occupation and family life, which may " blast 
his whole career and life, prevent marriage and 
self-support." This, unfortunately, has sometimes 
happened in the eagerness to make an early diagno- 
sis from physical signs alone without carefully con- 
sidering the symptoms. 

Physical Examination 
We come now to the physical examination of the 
patient, and in order to proceed methodically, it is 
well to have a plan or scheme, with a diagram of 
the chest upon which to note our findings. The 
following simple one is that which I find useful 
(Fig. 8). 




Fig. 8. Diagram for indicating physical findings 



DIAGNOSIS 63 

Examination of the Chest 

(a) Position of the Patient: — 

The patient should, in all cases, be stripped to 
the waist, with a sheet or some covering thrown 
about him, and seated upon a revolving stool. It 
takes considerable time for a careful examination 
and it is less tiresome both for the patient and phy- 
sician to be seated than to stand. The arms should 
hang loosely by the side when examining the front 
of the chest, and when examining the back the arms 
should be folded or one hand placed upon the op- 
posite shoulder when examining one or the other 
space between the scapula and the vertebrae for by 
this maneuver the scapula is pulled outward and 
one obtains more space between it and the spinal 
column. In examing the axilla, the hand should be 
placed upon the head. 

(b) Inspection: 

In inspecting the chest one should not be content 
with looking at it from the front, but also from the 
side and over the patient's shoulders. One should 
notice (a) the shape of the chest, as a whole, giving 
especial attention to the spaces above and below the 
clavicle to see whether there is more depression on 
one side than the other; (b) the appearance of the 
skin, its color, prominence of the veins, and any 
excrescences, such as swellings, and the neck should 
also be examined in this connection for scars in- 
dicating former adenitis, or for existing glands; (c) 
the respiratory movements, not only of the upper 
part of the chest, but also the diaphragmatic respira- 



64 PULMONARY TUBERCULOSIS 

tion. Particularly to be noted is delayed expansion, 
or less movement at one apex than at the other, 
which, when one can be sure of it, is a sign of value 
in early diagnosis. 

Pulse and Respiration 

The pulse and respiration should not be taken 
until the patient has had time to rest and become 
accustomed to the situation. If taken when he is 
more or less excited upon the first visit to the phy- 
sician, they will generally be above the normal rate. 
A much increased pulse rate, as has been observed, 
is of material significance, but in my experience, 
rapid respiration is of less importance, although it 
is suggestive. 

Examination of the Upper Respiratory Tract 

Before or after the physical examination of the 
chest, the upper respiratory tract should be investi- 
gated : — the nose, pharynx and larynx, and their 
condition and color of the mucous membranes noted. 
An anaemic, relaxed mucous membrane in these 
parts is often observed in pulmonary tuberculosis. 

The Weight 

First, the weight is taken with accurate scales 
and compared with the normal weight so far as we 
can learn it from the patient or estimate it. " In 
the diagnosis of early tuberculosis," says Lindsay, 
" the weighing machine plays a part hardly less im- 
portant than the stethoscope or the thermometer, 



DIAGNOSIS 65 

for wasting in some degree is one of the most con- 
stant symptoms." 

The Temperature 
The temperature taken once in the physician's 
office at whatever time the patient happens to be 
there is of little value unless it is ioo° F. or more. 
To obtain the real temperature variations, it should 
be taken at 8 a. m., 12 m v 4 and 6 p. m. for a period 
of a week, and the patient can readily be instructed 
to take it himself, or some one in the house can do 
it for him. A constant although slight rise of 
temperature (99. 5 or over) usually occurring in 
the afternoon, or a subnormal temperature if ac- 
companied by a persistently rapid pulse is very 
significant. When these two conditions, viz., a 
slight rise of temperature in the afternoon or a 
subnormal temperature and a rapid pulse are present 
and at the same time they are accompanied by a 
little loss of weight and strength and undue nervous- 
ness, the case for the existence of pulmonary tuber- 
culosis is a strong one. It is to be borne in mind 
that the above symptoms resemble those of neu- 
rasthenia and a diagnosis of the latter should not 
be made without a careful investigation as to the 
condition of the lungs. 

Outline of Percussion and Auscultation Sounds 
The following brief sketch of percussion and aus- 
cultation sounds will refresh one's memory as he 
proceeds to employ them in the next step of the 
examination. 



66 PULMONARY TUBERCULOSIS 

Percussion 

Prolonged practice is necessary to acquire skill 
in the practice of percussion. 

The sound which we obtain in percussing the 
lungs is called the percussion note. 

Percussion sounds have certain attributes or 
characteristics just as other sounds do, as the sound 
of a cannon, a violin, or a bell. Those attributes 
are: (a) quality; (b) intensity or loudness; (c) 
pitch, — high, low or intermediate; (d) duration 
(of least importance). 

The qualities of sound produced by percussing 
the chest may be included under three divisions : — 

I. Normal vesicular, or clear, — the sound given 
out by the healthy lung. Under this head we may 
include an abnormally clear sound called " hyper- 
resonant," found in emphysema for example. 

II. Dull sound, with the subdivisions: (a) slight 
dullness, (b) moderate dullness; (c) absolute dull- 
ness (flatness), present in varying degrees of con- 
solidation, pleural effusions, thickened pleura, pul- 
monary oedema, hemorrhagic infarction, and, in 
general, when the solids or liquids within the chest 
are abnormally increased without increase in the 
quantity of air (Flint). 

III. Tympanitic sound : a clear, hollow sound 
of a drum-like quality, such as heard in percussing 
a distended stomach or in a pneumothorax. It is 
devoid of all vesicular quality. This sound is eli- 
cited in more or less purity in pneumothorax, and 




Fig. 9. Anenbrugger 



DIAGNOSIS 67 

in cavities containing air. Varieties of tympanitic 
sounds are: (a) amphoric sound; occurring over a 
pulmonary cavity and in some cases of pneumo- 
thorax; (b) the cracked-pot sound, most often 
heard over large superficial air-containing cavities, 
and is the most infallible sign of a cavity known; 
is sometimes found in relaxed and infiltrated tissue 
(pleurisy and pneumonia). 

Pitch: The greater volume of air over which 
we percuss, the lower the pitch, and as the volume 
of air is diminished, pitch rises, like the large and 
small pipes of an organ; hence pitch is lowest in 
the tympanitic sound and highest in the dull sound. 
The first suggestion of impaired resonance is a slight 
heightening of pitch, a shallower sound : we com- 
monly call it, however, " slight dullness." 

Duration varies inversely with pitch; that is, the 
higher pitch the shorter duration, and vice versa. 
A deep toned bell vibrates longer than a high, shrill 
toned one. Intensity or loudness of sound depends 
upon thinness of chest walls and force of percussion. 

Auenbrugger's dictum (Auenbrugger discovered 
percussion and published a treatise upon it in 1761 ) : 
— Fig. 9. 

" Sonitus vel altior, vel prof undior ; vel clarior, 
vel obscurior, vel quandoque prope suffocatus de- 
prehenditur." 

"'The sound (i.e., the percussion sound), is a 
tone, clear or muffled, even to complete privation.' 
This is the first and great distinction. And next, 



68 PULMONARY TUBERCULOSIS 

1 the tone is of a pitch higher or lower.' Upon 
these two hang the whole theory and practice of 
percussion." * 

Auscultation 

Laennec, a celebrated French physician, discov- 
ered auscultation and published his first treatise upon 
it in 1819. Before Laennec, " clinical observation 
though never blind had been always deaf." Fig. 
10. 

Auscultation of the lungs is practiced with refer- 
ence to three kinds of sounds : — 

I. The sounds of breathing. 
II. The voice sounds. 

III. New or adventitious sounds (rales, fric- 
tion sounds). 

I. The breath sounds: There are three general 
types of breathing, — (a) normal or vesicular; (b) 
bronchial; (c) cavernous. When the breathing is 
part vesicular and part bronchial it is called " bron- 
cho-vesicular," or " rough " breathing or sometimes 
" harsh." 

(a) Vesicular breathing: Heard over normal 
lung. It may be normal in all respects and yet 
disease may exist, as in slight bronchitis, a few 
scattered tubercles, and early stage of pneumonia. 
Vesicular breathing may be altered as regards (a') 
intensity; (b') rhythm, (a') alterations in inten- 
sity : we may have ( 1 ) exaggerated vesicular breath- 

1 Gee " Auscultation and Percussion." London, 1893. 




Fig. 10. Laennec 



DIAGNOSIS 69 

ing (also called puerile) ; occurs on healthy side 
of chest when the respiratory function of the other 
side is interfered with, e. g., pleuritic effusion, 
pneumonia. (2) Diminished vesicular breathing 
(also called senile). Occurs when there is a thin 
layer of fluid between lungs and chest wall, or a 
thickened pleura, in emphysema, and in some cases 
of tuberculosis. (In large pleural effusions the 
respiratory sound is generally entirely absent.) 

(b") Alterations in rhythm. (1) prolonged ex- 
piration; occurs for example in emphysema (may 
or may not be a sign of disease). (2) Jerky or 
cogwheeled respiration, an uncertain sign, not of 
great importance. 

(b) Bronchial breathing (heard normally over 
trachea and at level of seventh cervical and upper 
five or six dorsal vertebrae). Occurs in disease in 
the following conditions: (1) consolidation of the 
lungs; from whatever cause (2) some cases of 
pleural effusion; (3) collapse of the lungs; (4) in 
certain cavities when the conducting bronchi are 
free. (Tubular breathing is an intense bronchial 
breathing with a metallic quality.) 

Broncho-vesicular or " rough " breathing : Oc- 
curs in different degrees of solidification of the 
lungs, e. g., in tuberculosis, pneumonia. The es- 
sential characteristics of broncho-vesicular breath- 
ing are a lengthening of the expiratory sound, and 
a roughening of both inspiration and expiration, 
and it means that more or less consolidation has 
taken place. 



jo PULMONARY TUBERCULOSIS 

(c) Cavernous breathing: Heard over a cavity, 
and is bronchial breathing rendered more intense 
by the reverberation of a cavity. 

II. Voice sounds: Spoken or whispered. We 
have (a) increased vocal resonance, (b) diminished 
vocal resonance, (c) absent vocal resonance, (d) 
bronchophony — all depending upon the condition 
of the conducting medium. Bronchophony is simply 
extremely increased vocal resonance, and is present 
under the same conditions as bronchial respiration. 

(a) Increased vocal resonance: Suggests either 
(i) solidification (more or less); or (2) a cavity. 
(Vocal fremitus suggests the same conditions as 
vocal resonance.) 

(b) Diminished vocal resonance: Suggests 
either (1) fluid in cavity; (2) thickening of pleura; 
(3) blocking of bronchial tubes with secretion; (4) 
pressure on lungs by tumor or aneurysm. 

III. New or adventitious sounds: (Rales and 
friction sounds.) Rales (always a sign of an ab- 
normal or diseased condition) are known as dry and 
moist. 

1. Dry rales — sonorous = low pitched. 

sibilant = high pitched. 
They are pathognomic of bronchitis. 

2. Moist rales — fine (crepitant). 

coarse. 
The terms " sub-mucous," " sub-crepitant," 
" crepitant," " sticky," " crackling " are names ap- 
plied to varieties of moist rales. Crepitant rales 
may be considered a sub-division of fine rales. All 



DIAGNOSIS 7 1 

moist rales are caused by the passage of air through 
liquid, which may be blood, mucus or serum. We 
have moist rales in bronchitis, cedema, pneumonia, 
tuberculosis hemorrhagic infarction, during and 
shortly after an hemoptysis, atelectasis. 

Friction sounds or pleural rales indicate pleurisy. 
Sometimes we have a coarse rubbing and sometimes 
an explosion of fine rales or what sounds like that. 
They are most commonly heard in the lower axilla. 
Cough does not affect friction sounds. 

It is an economy of time and convenient for sub- 
sequent reference to indicate upon a diagram of 
the chest, front and back, the abnormal physical 
signs detected, and for this purpose some system of 
signs is necessary. The one I have employed for 
many years is the following which is very simple 
and answers the purpose sufficiently well. It is 
hardly necessary to say that the whole chest should 
be examined, front, back, axillary region and base. 
It is true that, if tuberculous infiltration is present, 
evidence of it will almost always be found either in 
the supra- or infra-clavicular region, the supra- 
spinous fossa, or the inter-scapular space ; still, there 
are exceptions and one should always examine the 
entire chest. 

Systems of Signs for Recording Findings 



Dullness on Percussion 


Respiration 


Questionable dullness 


I 


(Diminished or feeble : — "Resp. 


Slight dullness 


II 


— " (minus), or > (Dim.) 


Moderate dullness 


III 


Respiration increased = 


Marked dullness 


IIII 


"Resp. +" or +-f- 


Flatness or intense 




Expiratory murmur increased 


dullness 


inn 


=" Exp't'n +." 



72 PULMONARY TUBERCULOSIS 

Dullness on Percussion Respiration 

Tympanitic = " O " Broncho-vesicular Resp. = 

Cracked Pot = " C. P." " B. V. ( + or + + ) " 

Bronchial Resp. = " Br." 
Amphoric =" Amph." 
Cavernous =" Cav." 

, R , ales . , ,. Voice Sounds 

If not heard with ordinary V ocal resonance dim.= 
, — ccgh- . . . " Voice — (minus) or > 

With full inspiration — c (dim)" 

respiration state with cough , V ocal resonance increased = 
full insp "Voice + or ++ " 

Fine dry dry clicks Bronchophony =" Br'y " 

Fine, medium or coarse moist Tactile Fremitus = T. F. 

rales, indicate by dots of Tactile Fremitus increased = 
varying size or small circles. T. F. + or H — h 

Sibilant — VV_ Tactile Fremitus decreased = 
Sonorous — VV T. F. > 

Friction sounds (pleuritic) Tactile Fremitus absent = T. 
# # # F.— (minus) 

Percussion 

In percussion one should begin with the front 
of the chest and go from below upwards ; for at the 
lower part of the chest one will generally get the 
normal resonance, and this can be taken as a stand- 
ard with which to compare the resonance higher up. 
Comparatively light percussion is preferable in front 
and heavier behind. Sometimes both light and 
heavy percussion in front will better bring out dif- 
ferences in resonance if they exist. It must be 
borne in mind that at the right apex there is a 
physiological difference in the percussion sound 
from that at the left apex : it is not so resonant and 
of higher pitch, and, moreover, the respiration is 
rougher, or broncho-vesicular in character, and the 
voice sounds decidedly more intense. All this is 



DIAGNOSIS 73 

normal for the right apex. As Cabot says, "We 
find at the apex of the right lung in health signs 
almost exactly identical with those of a slight de- 
gree of consolidation." In early cases there is 
rarely any dullness. The most that we shall, as 
a rule, find is some slight diminution of resonance 
and a heightened pitch, changes so slight that it is 
difficult to be sure that they exist. 

In making an early diagnosis, percussion will give 
us but little, if any, definite information. When 
unmistakable dullness is present, either an old ar- 
rested or inactive focus of consolidation of appre- 
ciable size exists, or, if active, the disease has passed 
beyond the initial stage. Sometimes when there is 
very considerable infiltration in both lungs, the per- 
cussion, although markedly impaired, may be so 
nearly the same on both sides, that one may not 
recognize that any dullness exists, particularly if 
there are no adventitious sounds. A mistake, and 
quite a natural one for a beginner, not infrequently 
made. 

Auscultation 

It is principally upon auscultation that one must 
depend for physical signs in early diagnosis, and 
here again such auscultatory signs will often be 
so indefinite that their interpretation becomes diffi- 
cult if not impossible. Both in percussion and aus- 
cultation one can better discriminate between slight 
differences in pitch and sound if he has a musical 
ear. Hence the advantage of being able to sing 
or play upon some musical instrument or the train- 



74 PULMONARY TUBERCULOSIS 

ing of one's ear in listening to good pure music. 
The elder Flint who was a consummate master of 
auscultation and percussion played the violin for 
years to " preserve the fine sense of pitch with which 
he was endowed." (Pryor.) Laennec, the in- 
ventor of mediate auscultation, played upon the flute, 
and Auenbrugger, the discoverer of percussion, was 
passionately devoted to music. 

It does not make so much difference what kind 
of a stethoscope one uses, provided he becomes ac- 
customed to it. It is very much like a sportsman 
who has become used to his own gun : it may have 
defects, but he has learned to make allowances for 
them, so that he can shoot more accurately with it 
than with a more perfect one with which he is not 
acquainted. So it is with the stethoscope which one 
constantly employs. 

First, one studies the respiration ; then the voice 
sounds, whispered and spoken, and finally seeks for 
adventitious sounds — rales. These latter, how- 
ever, may be the first abnormality detected, and if 
localized and constant, they go far towards making 
a definite diagnosis, for they are new sounds, while 
modifications in the respiration are only variations 
of normal sounds and are of uncertain interpreta- 
tion. 



CHAPTER V 

DIAGNOSIS, CONTINUED 

The Respiration 

In investigating the respiratory sounds one should 
first listen to quiet, ordinary breathing and then to 
deeper breathing, the mouth being slightly open; 
but no audible sound should be made in inspiration 
or expiration. It is often well to show the patient 
how you want him to breathe by doing it oneself. 

The ability to distinguish abnormal respiratory 
sounds must depend upon a clear recognition of the 
normal vesicular murmur, and the advice given by 
the elder Dr. Bowditch nearly seventy-five years ago 
in his "Young Stethoscopist " is excellent advice 
now: "You cannot study too frequently," he 
says, " or too minutely the respiratory murmur and 
the voice in healthy persons. One of the best ex- 
ercises you can have is the daily examination of 
three or four individuals who are free from thoracic 
symptoms. . . . For, in addition to having accu- 
rately learned the character of vesicular respiration, 
you will likewise have prepared yourself for the 
recognition of bronchial respiration and broncho- 
phony when they are the result of disease." 

One of the most significant modifications of the 
75 



76 PULMONARY TUBERCULOSIS 

respiratory murmur is what Turban calls " rough " 
breathing, which differs from the smooth sound of 
normal vesicular breathing in that it gives one the 
impression of air passing over a roughened surface, 
like riding in an automobile over a rough road in 
comparison with the easy rolling over a smooth one. 
At the same time, the respiratory murmur may be 
slightly diminished. Following the roughened in- 
spiration, we may have a clearly discernible pro- 
longed expiration, which may be more or less bron- 
chial in character. This rough respiratory mur- 
mur is considered the earliest auscultatory manifes- 
tation of a tuberculous invasion, and is produced 
by slight inflammatory changes in the bronchioli. 

Broncho-vesicular respiration is about the same 
thing as " rough " breathing considered from a 
different point of view. As the name implies, it is 
a mixture of the two kinds of murmurs, the bron- 
chial element occurring in the expiration which is 
prolonged. This sign, says Flint who introduced 
the name broncho-vesicular in 1856, " represents the 
different degrees of consolidation of the lung be- 
tween an amount so slight as to occasion only the 
smallest appreciable modification of the respiratory 
sound, and an amount so great as to approximate 
closely to the degree giving rise to bronchial respira- 
tion." 

It is well to repeat, that what we may consider a 
" rough " or broncho- vesicular murmur at the right 
apex, unless much exaggerated, is physiological at 
that apex, and, as Cabot says, " we find in the apex 



DIAGNOSIS 77 

of the right lung in health signs almost exactly 
identical with those of a slight degree of solidifica- 
tion " and " would mean serious disease if heard 
over similar portions of the left lung." 

I have often had students tell me, in the examina- 
tion of a patient, that they found bronchial respira- 
tion in one place or another when it did not exist; 
and, in order to show them their mistake, I tell them 
to listen to normal bronchial breathing over the 
larger bronchial tubes, a little below the trachea in 
front, and at the level of the seventh cervical and 
the upper five or six dorsal vertebrae behind, and 
compare the respiratory sound heard here with their 
supposed bronchial breathing. 

Genuine bronchial respiration is not, of course, 
an early sign. Sometimes one detects a definite dif- 
ference in the intensity of the vesicular murmur in 
the two apices. In one apex it is distinctly less 
intense. We call it diminished or weak respiration ; 
and when one is sure of the observation, it is a sign 
of considerable value in early diagnosis, and may 
be the only one we find. 

Cog-wheeled or intermittent breathing in my ex- 
perience is a sign of little value, for one so often 
hears it when there are no other symptoms or signs 
to indicate any pulmonary disease. At all events, 
when it occurs generally over the chest, it is of no 
importance; but when limited to one or both apices 
it may have some diagnostic value in combination 
with other signs. 

After all is said, slight modifications of the 



78 PULMONARY TUBERCULOSIS 

respiratory murmur are difficult of detection and 
of doubtful value. " Distinctions " (in the respira- 
tory murmur), says Gee, "which correspond with 
no definite physical condition of lung, make a show 
of profound and accurate knowledge, but really 
obscure it. They are idoli theatri." 

The Voice 

In order to make the auscultation of the voice of 
value, it must be fairly resonant, and hence with 
some persons, especially women, when the voice is 
thin and feeble, the evidence obtained from this sign 
is of little worth. The patient is told to utter slowly 
some sonorous word. I find the simple " one " as 
good as any ; others prefer " twenty-three " or 
" ninety-nine." It is to be borne in mind that 
normally the voice sounds are markedly louder at 
the right apex than at the left, and if one finds 
them of equal intensity at both apices, it is an in- 
dication that there is some infiltration at the left 
apex. The whispered voice is a more delicate test 
than the spoken one, and when it is of greater in- 
tensity and of a higher tone, it is indicative of some 
infiltration. In early cases, however, one will 
seldom be able to discern any appreciable difference, 
either in the spoken or whispered voice. Later, 
when there is definite consolidation, bronchophony 
appears over the consolidated area. 



DIAGNOSIS 79 

Tactile Fremitus 

Unless there are gross changes in the lungs, the 
tactile fremitus, or vocal thrill, will not be altered. 
At best it is a sign of very secondary importance. 

Rales 

Rales are, by far, of the most significance of all 
the auscultatory signs, for they are definitely ab- 
normal, and when persistent and localized, even if 
but a few and feeble, they have far greater weight 
in making an early diagnosis than any deviation 
in the respiratory murmur. Such rales as one hears 
in early cases are fine moist ones or " crackles," as 
some call them, generally heard only after cough. 
They are most commonly found above and below 
the clavicles, in the supra-spinous fossae behind, 
and in the upper and middle interscapular region. 

Although rales may not be theoretically consid- 
ered the earliest physical sign of pulmonary tuber- 
culosis, the great majority of physicians will make 
their diagnosis depend, so far as the physical signs 
are concerned, upon the discovery of rales, but they 
must be persistent and localized. In the examina- 
tion of normal chests I have often found, on the 
first full inspiration, a rale or two, due to the sud- 
den and unusual expansion of an atelectic lobule, 
but such rales disappear not to return after the 
first few full inspirations, and, therefore, they will 
not mislead one. One must never forget to have 
the patient cough and then take a full breath im- 
mediately thereafter, for thus rales will appear 



80 PULMONARY TUBERCULOSIS 

which would otherwise not be detected. Turban 
mentions the incident of a patient who had consulted 
many doctors and who decided their diagnostic abil- 
ity by whether or not they asked him to cough dur- 
ing examination. 

One must agree with Hector MacKenzie that 
" the earliest physical sign which is really charac- 
teristic is the presence of rales," localized rales. 
They are unmistakable, and they are almost pathog- 
nomonic. No pains is too great in the endeavor to 
elicit them. " Not infrequently," says Dr. Bow- 
ditch, " a sound like a simple whistle or a sonorous 
rale is heard under the clavicle, while in the re- 
mainder of the chest there is a healthy vesicular 
murmur; this strongly indicates the existence of 
tubercular disease if the patient is suffering from 
a chronic affection, especially if it is connected with 
any other distinctly morbid physical or rational 
sign." 

In making a physical examination one must not. 
neglect the base of the lungs, for occasionally in 
adults and more frequently in children the first phy- 
sical signs are discovered in the base of one or the 
other lung. With the adult, this means one of two 
things, either that the signs do not mean tuberculo- 
sis unless there is other corroborative evidence, or 
that there is also disease at the apex of the same 
lung which has not been discovered. If, however, 
we find evidence of basic affection and can find none 
at the top of the lower lobe, then the conclusion 
must be that the basic disease is not tubercular but 



DIAGNOSIS 81 

due to other causes, such as oedema, collapse, pleur- 
isy, bronchitis, broncho-pneumonia, or, possibly, to 
actinomycosis or syphilis. 

In doubtful cases one should go over the chest 
a second time, allowing the patient to rest between 
the two examinations. In this connection it is well 
to repeat again that in every suspected case an ex- 
amination of the sputum should be made and several 
times repeated if the tubercle bacilli are not found 
upon the first examination. Although one can 
often be morally sure that tuberculosis exists from 
the symptoms and physical signs, yet absolute cer- 
tainty can only be determined by finding tubercle 
bacilli in the sputum, for it is possible that the symp- 
toms which we regard as indicating tuberculosis may 
be caused by other conditions. " Active disease 
confined to one apex," says Glover 1 " with a repeat- 
edly negative sputum is not common." 

After the most careful physical examination, one 
will often be unable to detect definite evidence of 
disease, if he bases his diagnosis upon physical signs 
alone; for as Knight, one of the most acute ob- 
servers of our day, truly observes : " Variations 
in the respiratory murmur and slight modifications 
of the percussion note are not enough for a positive 
diagnosis," and " a patient should not be condemned 
to radical treatment upon such insufficient evi- 
dence." It is chiefly upon the symptoms that one 
must depend for an early diagnosis, unless he is 
fortunate enough to discover tubercle bacilli in the 

1 Quarterly Journal of Medicine, London, July 8, 1915, No. 32. 



82 PULMONARY TUBERCULOSIS 

sputum or detects persistent localized rales, or 
hemoptysis has occurred not referable to any other 
source than the lungs. " Amidst the niceties 
of our physical examinations," says Dr. Bowditch, 
to whose wisdom I have before referred, " we are 
apt to neglect the rational signs. The truth is that 
he who scoffs at either must necessarily be a child 
in the diagnosis of not a few diseases ; and he who 
cultivates both with the clear, keen-sighted eye of 
a true observer and then notes their mutual rela- 
tions is the truly wise physician." If from all the 
evidence obtained one is unable to make a probable 
diagnosis sufficiently strong to warrant active treat- 
ment, he must keep his patient under observation 
and make repeated examinations at short intervals. 
Another point to remember is that the localization 
of the signs is quite as important, if not more so, 
than their character. 

The following aphorisms of Lawrason Brown 
of Saranac Lake, 1 which are derived from a long 
and large experience, are most valuable guides. 
" For the beginner in work in pulmonary tubercu- 
losis," says Brown, " succinct opinions in diagnosis 
are of great assistance." 

I. " An appearance of ruddy health does not ex- 
clude tuberculosis." 

II. " In any patient with constitutional symp- 
toms, no matter of what he complains, the possibil- 
ity of tuberculosis must be kept constantly in mind." 

III. " Prolonged contact with tuberculosis may 
1 Journal of the American Association, June 12, 1915, Vol. 64, 

No. 24. 



DIAGNOSIS 83 

lead to infection, but debilitating conditions are nec- 
essary usually to cause this to develop into clinical 
tuberculosis." 

IV. " Constitutional or general symptoms lead 
us to a diagnosis of tuberculosis, while the localiz- 
ing symptoms point out the organs involved." 

V. " Loss of color, prolonged exposure to tuber- 
culous infection, especially in childhood, with a his- 
tory of swollen glands at that time, the more recent 
subjection to debilitating conditions, the presence of 
unequivocal constitutional and localizing symptoms, 
with or without the aforementioned complications, 
demand a diagnosis of pulmonary tuberculosis even 
though no abnormal physical signs are present in 
the lungs." 

VI. " Your patients, your friends, your family 
are as prone to contract and develop pulmonary 
tuberculosis as hundreds of others." 

VII. " The importance of physical examination 
in the diagnosis of pulmonary tuberculosis has been 
over-emphasized." 

VIII. " Symptoms are a better and more ac- 
curate guide to activity than physical signs." 

IX. " Symptoms without physical signs demand 
treatment, while physical signs without symptoms 
require only careful watching." 

X. " Slight but persistent rise in temperature, 
and increase in rapidity of pulse are often present 
early in the disease." 

XI. " Failure to interpret rightly the significance 
of symptoms, to detect the presence of abnormal 



84 PULMONARY TUBERCULOSIS 

physical signs can be condoned; but failure to ask 
for and examine the sputum repeatedly in any 
patient with chronic cough is inexcusable." 

XII. " Absence of tubercle bacilli in the sputum 
means only that bronchial ulceration has not oc- 
curred." 

XIII. " The usual weight of a patient who de- 
velops pulmonary tuberculosis is often ten pounds 
below the normal weight for his height and age." 

XIV. " The detection of rales by the ausculta- 
tion of the inspiration following cough is the most 
important procedure in the detection of physical 
signs of early pulmonary tuberculosis." 

XV. " The disease is practically always more ex- 
tensive than the physical signs indicate." 

XVI. " Abnormal physical signs at one apex 
should be considered as due to pulmonary tuber- 
culosis, until proved not to be, while those at the 
base should be looked on as non-tuberculous until 
definitely proved so." 

XVII. " When sputum is lacking or when tuber- 
cle bacilli are absent on repeated examinations the 
possibility of the presence of bronchiectasis, hyper- 
thyroidism, syphilis and influenza and more rarely 
pulmonary tumor and Hodgkin's disease should be 
borne in mind." 

XVIII. " It may be impossible to determine defi- 
nitely the presence or absence of clinical tubercu- 
losis." 



DIAGNOSIS 85 

The X-Ray in Diagnosis 

There are two other aids that may render a 
doubtful diagnosis certain: the X-ray and the tu- 
berculin test. In order to be of much value the 
X-ray plate should be made by an expert technician 
who is also skilled in the interpretation of the 
roentgenogram or of the fluoroscopic picture. More- 
over, one must be thoroughly familiar with the 
X-ray picture of the normal lungs. Under these 
circumstances the X-ray may " reveal and locate 
pathologic pulmonary changes to be detected by no 
other means" (Brown). It tells us nothing, how- 
ever, as to the activity or non-activity of the lesion. 
Moreover, it often reveals more extensive disease 
than the physical signs show. If a tuberculous 
lesion is present the X-ray picture will indicate it 
by opacities, shading or mottling at the apex, or 
elsewhere, often difficult to detect and interpret. 
The X-ray is only an exceptional expedient when 
all other means fail ; generally one can better spend 
his time in gaining perfection in diagnosis from the 
symptoms and physical signs, than in attempting to 
become skilled in the use of the X-ray or in the 
interpretation of its revelations. 

The Tuberculin Test 

This test, as generally employed, is of two forms : 
(a) the von Pirquet vaccination test, and (b) the 
subcutaneous one. 

(a) The von Pirquet Test. 



86 PULMONARY TUBERCULOSIS 

This test is chiefly useful with children under 
five years of age. It consists in slightly scratch- 
ing the arm, after it has been cleaned with alcohol, 
with a sterilized needle or some sharp-pointed 
instrument, not deep enough, however, to draw 
blood. Three spots are thus scarified and upon 
two of them a drop of full strength old tuber- 
culin (O. T.) is placed, while the third is left 
for a control. After ten minutes what remains 
of the tuberculin is wiped off and no dressing 
is applied. A reaction, if it occurs, will appear 
in from twenty- four to forty-eight hours, and will 
be indicated by a red raised areola at the site of the 
vaccination about the size of a penny, while the 
control spot will show nothing. As, according 
to von Pirquet, ninety per cent, of persons over 
fourteen years of age give a positive reaction, 
the test with adults is generally positive and only 
shows that there is a tuberculous lesion somewhere 
in the body, but tells us nothing as to its activity. 
A negative reaction in general indicates the absence 
of tuberculosis, 
(b) The Subcutaneous Tuberculin Test: 

In this test a minute amount of Koch's old tuber- 
culin (O. T.) is employed, which can be prepared 
by diluting the original full strength tuberculin, or 
the dilutions can be obtained already made. So 
many tenths of a c.c. of the diluted tuberculin will 
contain the amount we wish to use. A syringe 
graduated in tenths of a c.c. is employed, and 
aseptic precautions, as with ordinary subcutaneous 



DIAGNOSIS 87 

injections, are, of course, taken. The injections are 
made preferably in the back below the angle of the 
scapula, although any other muscular portion of the 
body may be selected. The dose at first is one- 
fifth of a milligram, and if no reaction occurs, then 
one milligram and, finally, five to ten milligrams at 
three-day intervals. The patient must be afebrile, 
for a rise in temperature is one of the most impor- 
tant signs of a reaction. 

The reaction is threefold: (a) local; (b) 
focal; (c) general; and it occurs in from four to 
thirty-six hours, the general reaction usually taking 
place in from four to twelve hours. The local re- 
action is indicated by redness and swelling at the 
site of the injection ; the focal by signs of increased 
activity in the suspected focus of disease in the 
lungs, such as pain, increased cough and expector- 
ation, and if rales were previously present, they are 
more evident. The general reaction consists of a 
rise of temperature from ioo° to 102 F. or more; 
general malaise much like that from an attack of 
influenza, with headache, pain in the joints and 
back, anorexia, sweating, weakness and frequently 
nausea and vomiting. It is generally best to keep 
the patient in bed from twenty-four to forty-eight 
hours after the injection, although this cannot al- 
ways be realized, and the test can be made with 
ambulatory patients, and they can be instructed to 
take their temperature at home. 

The subcutaneous tuberculin test in the doses 
indicated above is without danger and can be safely 



88 PULMONARY TUBERCULOSIS 

employed, and it is the most reliable of all the 
methods of using tuberculin for early diagnosis. 
It is to be remembered that a reaction only indicates 
that there is a tuberculous focus somewhere in the 
body; it does not tell us where it is or whether or 
not it is active and treatment is required. With 
other evidence, however, of active tuberculosis, it 
renders the diagnosis more certain, but does not 
make it positive. A failure to react, after a thor- 
ough trial, either gives us a probable assurance that 
no tuberculosis exists, or that the disease is so far 
advanced that the reactive forces of the body have 
lost their power. One of Brown's aphorisms is 
pertinent here; he says: 

" No modification of the tuberculin tests as yet 
devised differentiates clearly clinical tuberculosis 
that demands vigorous treatment from non-clinical 
tuberculosis that requires only a God-fearing life." 

The Stages of Tuberculosis 

The following classification, essentially that 
adopted by the National Association, is generally 
employed in grouping the different stages of the 
disease. 

I. Incipient: Slight infiltration limited to the 
apex or a small part of one lobe. Slight or no con- 
stitutional symptoms (particularly including gas- 
tritis or intestinal disturbances or rapid loss of 
weight). Slight or no elevation of temperature 
or acceleration of pulse at any time during the 
twenty- four hours; especially if at rest. Expector- 



DIAGNOSIS 89 

ation, usually small in amount or absent. Tubercle 
bacilli may be present or absent. No tuberculous 
complications. 

II. Moderately Advanced: No marked impair- 
ment of function, either local or constitutional. 
Localized consolidation moderate in extent, with 
little or no evidence of destruction of tissue, or dis- 
seminated infiltration. No tuberculous complica- 
tions. 

III. Far Advanced: Marked impairment of 
functions, local and constitutional. Localized con- 
solidation, intense or disseminated areas of soften- 
ing, or serious tuberculous complications. 

Such a classification is more or less unsatisfactory 
because in practice the extent of the physical signs 
in many cases does not agree with the symptoms of 
the stage to which the signs belong; for example, 
the physical signs may indicate a moderately ad- 
vanced or a far advanced case, while there are only 
the symptoms of an incipient case. To remedy this, 
Dr. Rathburn of the Otisville Sanatorium, N. Y., 
has suggested the following classification of the 
physical signs and symptoms. 
Physical Signs: 

Stage I. Slight infiltration limited to the apex of 
one or both lungs or a small part of one lobe. No 
tuberculous complications. 

Stage II. Localized consolidation, moderate in 
extent, with little or no evidence of cavity forma- 
tion, or infiltration more than under incipient 
(Stage I). No serious tuberculous complications. 



90 PULMONARY TUBERCULOSIS 

Stage III. Marked consolidation of an entire 
lobe, or disseminated area of beginning cavity for- 
mation; or serious complications. 
Symptoms : 

A. (Slight or none.) Slight or no constitu- 
tional symptoms (including particularly gastric or 
intestinal disturbance or rapid loss of weight.) 
Slight or no elevation of temperature or acceleration 
of pulse at any time during the twenty- four hours. 
Expectoration, usually small in amount, or absent. 
Tubercle bacilli may be present or absent. 

B. (Moderate.) No marked impairment of 
function, either local or constitutional. 

C. (Severe.) Marked impairment of function, 
local and constitutional. 

Thus, for example, a patient with physical signs 
of a far-advanced lesion (Stage III), with no 
marked impairment of function, either local or con- 
stitutional, would be classified III B ; or a mod- 
erately advanced case as to the physical signs ( Stage 
II), with incipient symptoms would be classified as 
II A. In this way, one obtains an accurate idea 
of the extent of the lung involvement, and also of 
the toxsemic state of the patient. 

Further Advanced Disease 

When the disease has advanced beyond the early 
stage, the diagnosis, as a rule, is more readily made, 
— the symptoms are more evident, and the physical 
signs more definite : — toxsemic indications show 
themselves and rales are generally present. 



DIAGNOSIS 91 

Moderately Advanced Tuberculosis 

In this stage there is more or less solidification, 
and, if slight, it may be difficult to recognize it, 
especially if at the right apex. The resonance will 
be impaired and the breathing will be rough, or 
broncho-vesicular. The voice sounds, also, will be 
intensified. There will often be some softening, 
indicated by rales of varying size and by the ex- 
pectoration. Some of the unmistakable symptoms 
of tuberculosis, such as cough, weakness, loss of 
weight, rapid pulse and rise of temperature will 
generally be present. 

More Advanced Tuberculosis 

As softening proceeds, the character of the rales 
changes : they are more numerous, larger and more 
liquid. With the increase of the consolidation, the 
breath sounds approach the bronchial type, and 
bronchophony is present over the diseased area. 
When a cavity exists, it is not always easy to recog- 
nize it, and it does not make much difference if it is 
not detected, for the other evidence indicates the 
state of the case. " Practically," says Gee, " the 
physical diagnosis of excavation mostly comes to 
this: that in progressive phthisis a cavity is pre- 
sumed to be present where the bronchial breathing 
is most intense." The signs usually relied upon for 
the diagnosis of a cavity are (a) amphoric or cav- 
ernous respiration; (b) cracked-pot resonance on 
percussion, and dullness; (c) coarse gurgling rales. 

When contraction takes place after excavation, 



92 PULMONARY TUBERCULOSIS 

the normal expansion of the diseased side is either 
markedly decreased or absent, there is woodeny 
dullness over the area and there may be complete 
absence of breath sounds; or, if the arm is raised, 
one generally hears cavernous respiration in the 
apex of the axilla. The cavity is generally dry and 
rales are absent. With the contraction, the heart 
is more or less displaced ; if the contraction is in 
the upper left lobe, the heart may be displaced 
upwards; if in the right upper lobe, it may be dis- 
placed to the right. In the opposite lung, if not 
diseased, there is generally compensatory hyper- 
trophy, with increased functional activity, indicated 
by rough breathing and prolonged expiration. 

Mode of Advance of Pulmonary Tuberculosis 

From the primary focus which, in the large ma- 
jority of cases, is at the apex, the disease usually 
extends downward along the anterior aspect of the 
upper lobe. Next, the apex of the lower lobe of 
the same side is usually affected, often long before 
any extensive infiltration or softening has occurred 
in the upper lobe, and generally before the opposite 
lung is attacked. The bases are often but little 
affected and may not be at all. The spread of the 
disease in the opposite lung takes place in the same 
way. Fowler has observed that the earlier lesion 
does not occur at the actual summit of the apex, 
but one to one and one-half inches lower, corre- 
sponding in front with the middle of the clavicle. 
From this part the lesions spread at first chiefly 



DIAGNOSIS 



93 



backward, so that the signs behind are more evident 
than those in front. Fowler also mentions that a 
favorite early spot for secondary infection is the 
middle of the interlobar septum, corresponding with 
a spot in the upper part of the axilla; hence, one 
should always carefully examine this region. 

As the disease progresses, both sides, as a rule, 
become involved, but often not equally so. In the 
incipient stage one rarely finds both apices affected 
at the same time. 




Fig. ii. 



Showing the common seat of the earliest tuberculous 
lesions (after Fowler) 



Differential Diagnosis 

(a) Actinomycosis: 

There are other conditions and diseases which 
may be mistaken for tuberculosis, some rare and 
others more common, (a) Actinomycosis is one 
which may first manifest itself in the lungs. The 
physical signs, however, are usually basic while the 



94 PULMONARY TUBERCULOSIS 

apices are clear. The occupation of the patient 
which causes him to deal with cereals ; the presence 
of lesions elsewhere in the body; the pain; the ab- 
sence of tubercle bacilli in the sputum or in the pus 
from an abscess, after repeated examinations and 
the detection of the ray-fungus will clear up the 
diagnosis. It is not a common disease, but it oc- 
curs, and I have mistaken it for tuberculosis. Of 
course, it may be associated with tuberculosis in the 
same individual. 

(b) Malignant Disease of the Lungs: 

This is also rare, and can hardly be mistaken. 
There is a history of pre-existing malignant disease 
in other parts of the body ; marked rapid cachexia ; 
severe persistent localized pain ; absence of tubercle 
bacilli in the sputum. The physical signs are more 
likely to be found in the middle or base of the lung, 
and do not advance as in pulmonary tuberculosis. 
We may have bloody pleural effusion, but this may 
occur also in tuberculosis. If there is doubt as to 
the diagnosis, the X-ray will be of service. 

(c) Pulmonary Syphilis is of still rarer occurrence, 
although the co-existence of syphilis and tubercu- 
losis is not infrequent. From the physical signs 
one cannot differentiate pulmonary syphilis from 
pulmonary tuberculosis. The points which suggest 
the former disease are (a) more extensive physical 
signs than the symptoms would indicate; (b) the 
history of and evidence of syphilis elsewhere in the 
body; (c) the absence of tubercle bacilli; (d) 
laryngeal and pharyngeal lesions; (e) the effect of 



DIAGNOSIS 95 

anti-syphilitic treatment. When doubt exists a 
Wasserman test should be made. 

(d) Influenza: 

This infection often simulates very closely pul- 
monary tuberculosis. The constitutional symptoms 
and physical signs may be quite similar. The 
physical signs are more likely to be found at the 
base than at the apices of the lungs; still, we may 
have dullness, rales and modified breathing at the 
latter location. The sputum, which is purulent, 
does not contain tubercle bacilli, but does the in- 
fluenza bacillus. In influenza the constitutional 
symptoms may not be so severe as the apparent 
extent and activity of the lung process would indi- 
cate, nor is the disease generally so chronic or pro- 
gressive. Often a patient gives the history of a 
previous attack of influenza which may have been 
an active outbreak of a latent tuberculous focus, 
which latter again became inactive. 

(e) Malaria: 

Formerly the mistake was common of treating a 
case of tuberculosis for malaria from error in diag- 
nosis. At the present time, a careful physical ex- 
amination, together with that of the blood and 
sputum, and, if necessary, the therapeutic test of 
Quinin ought to clear up any doubt. 

(f) Bronchiectasis: 

The history, course and physical signs differ in 
this disease from those in pulmonary tuberculosis. 



96 PULMONARY TUBERCULOSIS 

In bronchiectasis we have the history of a prolonged 
bronchitis with intermittent expectoration of a pro- 
fuse, ill-smelling sputum in which tubercle bacilli 
are absent. Generally there is no pyrexia, and the 
constitutional symptoms are slight. The physical 
signs are generally at the base and suggestive of 
a cavity. 

(g) Bronchitis: 

Many a poor consumptive has been deluded by 
the diagnosis of " bronchitis " or " bronchial affec- 
tion " because he had a lingering and severe cough, 
and lost his golden opportunity for treatment; and 
yet the differential diagnosis is not difficult. In 
bronchitis the physical signs are almost always bi- 
lateral and consist mainly of a variety of rales, 
especially bubbling and sibilant, similar on both 
sides, and more often confined to the bases of the 
lungs; there is no dullness and little if any change 
in the respiratory murmur. The constitutional 
symptoms are not commensurate with the extent of 
the disease as indicated by the rales ; there is no 
such loss of weight or strength and the increased 
temperature does not persist; the sputum shows no 
tubercle bacilli. Nevertheless, one must bear in 
mind the fact that a bronchitis may mask an under- 
lying tuberculous lesion and only continued obser- 
vation and examination of the sputum, or an 
hemoptysis will clear up the doubt. 

(h) Neurasthenia: 
In this condition the effect has not infrequently 



DIAGNOSIS 97 

been taken for the cause. The debility, anaemia, 
loss of flesh, anorexia, digestive disturbances, and 
perhaps cough, — some or all of which may be pres- 
ent in the supposed case of neurasthenia, may be 
due to a tuberculous infection. In the former case, 
however, there is no pyrexia, no tubercle bacilli in 
the sputum, if there is any sputum, and no physical 
signs discoverable. In every case of supposed 
neurasthenia the possibility of tuberculosis should 
be kept in mind, and a thorough physical examina- 
tion always made. In not a few instances one will 
have to suspend judgment and keep the patient 
under observation. Fortunately in both conditions 
the treatment is essentially the same. 

(i) Asthma: 

Asthmatic signs may mask a tuberculous lesion, 
and one can only wait for an opportune moment 
when such signs are absent to make a satisfactory 
examination. The history, examination of the 
sputum, and the general symptoms will generally 
lead one toward a correct diagnosis. 

(j) Pleurisy: 

Pleurisy is so often secondary to tuberculosis that 
a careful examination should always be made of 
the lungs to detect a primary tuberculous focus. 
We may find fine rales at the apex, but in case of 
pleurisy they are not lasting. If there is an ef- 
fusion, and no other evidence of tuberculosis, ani- 
mal inoculation may be necessary to determine the 
nature of the fluid. 



9 8 PULMONARY TUBERCULOSIS 

(k) Cardiac Lesions: 

The heart should always be examined when in- 
vestigating the condition of the lungs ; otherwise 
one may sometimes be deceived when hemoptysis 
and cedema are present, as in mitral lesions, espe- 
cially stenosis. 

Other Diseases and Conditions 
Persistent anaemia, chlorosis, dyspepsia with loss 
of weight, a localized suppurative process, hyper- 
thyroidism, and, rarely, Hodgkin's disease, present 
some of the ear-marks of pulmonary tuberculosis ; 
but a careful investigation will differentiate them 
from the latter disease. 

Three aphorisms of Gee may form a fitting close 
to this chapter upon diagnosis : 

(a) " Almost every chronic affection of the apex 
of the lung is tubercular in origin." 

(b) " Therapeutics must begin before physical 
signs have developed; if you wait for physical signs 
you wait too long." 

(c) "In a young man an attack of hemoptysis 
is quite sufficient indication for treating him for 
pulmonary tuberculosis. It is not so in the case of 
a young woman." 



CHAPTER VI 

PROGNOSIS 

" There is a history in all men's lives," 

" Figuring the nature of the times deceas'd." 

" To which observ'd a man may prophesy," 

" With a near aim, of the main chance of things " 

" As yet to come to life, which in the seeds " 

" And weak beginnings lie entreasured." 

Henry IV, Part II, Act III, Sc. i. 

When a definite diagnosis of pulmonary tuber- 
culosis has been made, the patient naturally wants 
to know what are his chances of recovery, and 
although it is obviously impossible to give any posi- 
tive opinion without the observation of the patient 
for a period of time, while he is under treatment, 
and gauge the response of his defensive forces ; yet 
there are certain indications which the history and 
examination may have revealed, which will aid us 
in forming some estimate of the future course and 
result of the disease. 

Definition of " Cure " 

What is generally meant by a " cure " is not a 
" restitutio in integrum," as though the disease had 
never existed, but a permanent arrest of the infec- 

99 



ioo PULMONARY TUBERCULOSIS 

tion and its local process, so that the individual is 
restored to his former life of activity; he is clin- 
ically, or, as some choose to call it, " economically " 
well. What is the probability of obtaining this 
desired result is the question to be answered. 

In studying the individual case in reference to 
the prognosis, all the factors involved, past and 
present, should be considered, and no one factor 
should be regarded as of paramount importance; 
physical signs alone should not constitute the basis 
of the prognosis, for the symptoms are of equal if 
not greater importance. " The nature of the symp- 
toms," says Lindsay, " probably give us the most 
trustworthy of all prognostic indications." To go 
beyond the present indications, the most reliable 
guide, as has been referred to above, is the reaction 
of the patient under treatment. After a sufficiently 
extended trial, if there is no response, the patient 
is doomed. 

I once remarked to Walther, the head of a well- 
known sanatorium in Germany, that I supposed he 
only received early cases. " I take all kinds of 
cases," he replied. " I never can tell whether they 
will recover or not." There are early cases, so far 
as the physical signs are concerned, who develop 
no resistance and the disease pursues a steady down- 
ward course, do what we will ; and, on the contrary, 
there are other more-advanced cases, who show re- 
markable response to treatment and eventually 
arrive at an enduring arrest. But few cases, then, 
should be pronounced absolutely hopeless. 



PROGNOSIS 101 

General Propositions 

The general propositions to be kept in view in 
giving a prognosis are well stated by Lindsay. 1 

( i ) " Whether there is a reasonable hope of 
complete recovery." 

(2) " Whether the case is, upon the whole, fav- 
orable, a good rally probable and treatment likely 
to repay its cost in time and money." 

(3) "Whether the case is, upon the whole, un- 
favorable, and admitting only a moderate degree 
of improvement." 

(4) " Whether the case is definitely unfavorable 
and admitting only a slight degree of palliation." 

( 5 ) " Whether the case is obviously hopeless and 
systematic treatment useless." 

It is self-evident and proved by experience that 
the earlier the disease is diagnosed and treatment 
instituted, the better the prognosis, and, on the con- 
trary, the later the disease comes under treatment 
the more unfavorable the prognosis, but there are 
not a few exceptions. 

Especial Indications 

(a) Character of the onset: 

The more acute the onset, as it were, an advanced 
case from the beginning, the less favorable is the 
prognosis, while an insidious onset is of no definite 
prognostic significance. 

(b) The rate of progress in relation to the dura- 
tion of the symptoms : 

1 " Diseases of the Lungs." N. Y. 1904. 



102 PULMONARY TUBERCULOSIS 

If the disease has existed but a short time and 
yet there is evidence of rapid extension and de- 
struction of lung tissue, or both lungs are involved 
at an early period, the prognosis is unfavorable. 

(c) The character of the constitutional symp- 
toms: 

If these are marked, such as persistent high 
temperature, rapid pulse (either with or without 
fever), progressive loss of weight and strength, 
anorexia and digestive disturbances, the prognosis 
is unfavorable, while, on the contrary, absence of 
pyrexia, a gain in weight, diminished cough and 
expectoration are favorable signs. 

(d) Increase of moisture in the diseased portion, 
as indicated by the increase and size of moist rales 
is unfavorable, even if there is general improve- 
ment. 

(e) Any serious complication, either tuberculous 
or non-tuberculous, such as diabetes, albuminuria, 
syphilis, laryngeal tuberculosis, chronic diarrhoea, 
peritoneal or intestinal tuberculosis, render the 
prognosis more unfavorable. Pregnancy has gen- 
erally been considered an unfavorable complication, 
but it is not invariably so; much depends upon the 
stage and activity of the disease at the commence- 
ment of the pregnancy. Occasionally actual im- 
provement has taken place as a result of the condi- 
tion. As a rule, however, pregnancy, in an active 
state of the disease, must be regarded as of unfav- 
orable prognostic significance. Fistula-in-ano does 
not materially affect the prognosis, nor does an in- 



PROGNOSIS 103 

tercurrent pleurisy; if there is effusion, whether 
removed by absorption or aspiration, the favorable 
course of the disease may go on thereafter uninter- 
ruptedly. Various acute diseases occurring shortly 
before the advent of the tuberculosis, render the 
prognosis rather more unfavorable, such as influ- 
enza, pneumonia, typhoid fever, bronchitis, and 
whooping cough and measles in children. They 
lower the resistance of the patient to the new tuber- 
culous infection. When the constitutional symp- 
toms are marked and out of proportion to the 
physical signs indicating the virulence of the in- 
fection and ascendency of the toxaemia, the outlook 
is unfavorable unless resistance can be promptly de- 
veloped by treatment; and when the physical signs 
and symptoms are at variance the symptoms are a 
safer prognostic guide than the physical signs. 

Bearing of the Previous Life and Habits upon the 
Prognosis 

If the patient has lived a regular life under good 
hygienic conditions as to food, fresh air and rest, 
and yet develops pulmonary tuberculosis, the prog- 
nosis is less favorable in his case than that of one 
who has lived and worked under unwholesome 
hygienic conditions and been subjected to depriva- 
tions of one kind or another, for the treatment in 
the latter case is a more radical change in his mode 
of life than in the former case and may be expected 
to elicit a more ready and marked response. In the 
one case the unhygienic conditions of living may 



104 PULMONARY TUBERCULOSIS 

justly be regarded as the exciting cause of the tuber- 
culosis, while in the other we can only refer the 
development of the disease to an inherent lack of 
resistance. 

Family Prediposition 

How much importance should be attributed to 
the family history in estimating the prognosis it is 
difficult to say; in general, a rather more guarded 
prognosis should be given in the case of a patient 
with a tuberculous family history. That families 
vary in resistance to infection is a familiar fact; 
but that a specific lack of resistance to the tubercle 
bacillus exists in those of a tuberculous family his- 
tory is questionable; a weak constitution, however, 
may be inherited which renders one more suscep- 
tible to any infection. Tuberculosis in one's imme- 
diate family may indicate a family predisposition 
to the disease or merely greater opportunities for 
contracting it. 

The Temperament 

Again, the temperament of the patient has a bear- 
ing upon the prognosis: We have the nervous 
type, represented by a person who is easily fatigued, 
has an indifferent appetite and poor digestion, and 
who sleeps but poorly ; or the lymphatic type, which 
feebly responds to treatment, and in which loss of 
strength and a general depressed condition are the 
prominent symptoms. The physical signs may be 
slight and the symptoms subacute, and the patient 
may look pretty well ; but with this type, as with the 



PROGNOSIS 105 

preceding one, the prognosis must be guarded. On 
the other hand, there is the thin, sinewy type, with 
much endurance, a good appetite and digestion and 
a strong heart, — a type in which the local lesion 
is limited and tends to fibrosis rather than soften- 
ing; and the hemorrhagic type in which small re- 
curring hemorrhages occur, without effect upon the 
general condition, and in which the physical signs 
are insignificant. Both of these types offer a very 
fair chance of recovery. 

Character and Intelligence of the Patient 

A patient of determination and intelligence, who 
thoroughly grasps the situation, and is resolved to 
faithfully and persistently carry out the treatment 
and co-operate with his physician, obviously offers 
a better prognosis than one accustomed to self- 
indulgence, who has always had his own way, and 
who will not submit to the rigorous training in- 
volved in the treatment. As some one has 
facetiously, but with a good deal of truth said, 
" It depends more upon what is above the collar 
than what is below, whether or not one recovers." 
Ignorance and an inability to comprehend the situ- 
ation and intelligently follow the indications, render 
the prognosis far less favorable : " It is impossible 
to cure a fool." 

Age and Sex 

As a rule, the very young and the old do badly, 
while the prognosis is best in early adult life. As 



106 PULMONARY TUBERCULOSIS 

to sex, the prognosis seems to be rather more favor- 
able in the male sex ; but this may be due merely to 
the different habits and mode of life of the two 
sexes. 

Various Other Conditions 

The occupation; social status; financial ability to 
obtain the proper treatment; the habits, particularly 
as to the use of alcohol, or other excesses, are all 
obvious points to be considered in the prognosis. 

Food 

A most vital indication with regard to the prog- 
nosis, while the patient is under treatment, is the 
matter of the ingestion and digestion of food. If 
he can eat and digest the requisite amount of food 
and be nourished by it, it is an exceedingly favor- 
able prognostic omen. If, as Napoleon said, " an 
army marches upon its belly," so a consumptive 
fights his disease with his stomach. " A consump- 
tive who cannot eat is doomed." 

Final Summary 

In estimating the probable outcome in any indi- 
vidual case, the final judgment must be based upon 
the resistance of the patient to the bacilli and their 
toxins. The result depends upon the issue of the 
conflict between these two opposing forces, and only 
after a period of observation of the contest can we 
form a reasonable opinion as to the ultimate result. 

Let us marshal the two opposing forces. The 
activity of the infecting forces, which means vie- 



PROGNOSIS 107 

tory for them, is indicated by the following' symp- 
toms and signs: 

(a) Rapid and low tension pulse. 

(b) Fever. 

(c) Steady and rapid loss of weight. 

(d) Anorexia and digestive disturbances. 

(e) Loss of strength. 

(f) Marked dyspnoea. 

And with reference to the local process, evident 
extension and softening, with numerous tubercle 
bacilli and a variety of rales. 

On the side of the resistance, as indicating vic- 
tory, we have: 

(a) No fever. 

(b) Quiet pulse and nervous system. 

(c) Weight not diminished or increasing. 

(d) Good appetite and digestion. 

(e) Strength not materially lessened. 

And the local process limited and not advancing. 
It is well again to repeat that the physical signs 
may be very slight and yet the constitutional symp- 
toms marked, indicating that the toxoemia has over- 
come the resistance ; or, on the other hand, we may 
have extensive physical signs with few or no con- 
stitutional symptoms, indicating that at least an 
equilibrium or stalemate, more or less permanent, 
exists between the opposing forces. 

Scheme of Results 

The scheme of results adopted by the National 
Association for the Study and Prevention of Tuber- 



108 PULMONARY TUBERCULOSIS 

culosis and the American Sanatorium Association 
in 19 13 is as follows: 

I. Apparently cured: All constitutional symp- 
toms and expectoration with bacilli absent for a 
period of two years under ordinary conditions of 
life. 

II. Arrested : All constitutional symptoms and 
expectoration with bacilli absent for a period of six 
months, the physical signs to be those of a healed 
lesion. 

III. Apparently arrested: Same as above, ex- 
cept for a period of three months. 

IV. Quiescent: Absence of all constitutional 
symptoms; expectoration with bacilli may or may 
not be present; physical signs stationary or retro- 
gressive ; the foregoing condition to have existed at 
least two months. 

V. Improved : Constitutional symptoms less- 
ened or entirely absent ; physical signs improved or 
unchanged ; cough and expectoration with bacilli 
usually present. 

VI. Unimproved: All essential symptoms and 
signs unabated or increased. 



CHAPTER VII 

TREATMENT 

" I cannot help believing that medical curative treat- 
ment will resolve itself in great measure into modifications 
of the food swallowed, and breathed, and of the natural 
stimuli, and that less will be expected from specifics and 
noxious disturbing agents." 

O. W. Holmes, 1861. 

Cases Requiring No Treatment 

In the first place, one should bear in mind that 
pulmonary tuberculosis which has been diagnosed 
by the physical signs alone, and is without symp- 
toms, requires no treatment. Symptoms are the 
indication of active disease, and for active treat- 
ment. This point needs to be emphasized, for it 
has happened that individuals have been condemned 
to unnecessary treatment, their accustomed life dis- 
arranged, and their domestic economy upset, solely 
upon the ground that physical signs were dis- 
covered. 

The Patient Should Be Told His Condition 

At the outset the patient should be told, in a 
kindly and tactful way, his condition, and the hope- 
ful outlook in his case, supposing it is a curable 
109 



no PULMONARY TUBERCULOSIS 

one, if he conscientiously follows out the treatment 
and co-operates with his physician. It should be 
impressed upon him that disaster is likely to follow 
if he neglects or defers the proper treatment. The 
same should, likewise, be said to his family or 
friends. The treatment is then explained in detail, 
and the plan for the individual case arranged, 
whether the treatment is taken in or out of a sana- 
torium. 

Principle^ of the Treatment 

Like the snakes in Ireland, there is no remedy for 
pulmonary tuberculosis in the sense of a specific 
medicine or form of treatment directly applied to 
the exciting cause, — the tubercle bacillus. In- 
numerable supposed specifics have been proposed 
and tested, but all have been found wanting. The 
only treatment which has successfully stood the test 
of time and experience is the indirect one of de- 
veloping and maintaining the resistance of the indi- 
vidual to the toxaemia of the infection. We name 
it the " hygienic-dietetic " or " open-air " treat- 
ment. In brief, it consists (a) in breathing pure 
out-door air night and day; (b) an abundance of 
nourishing food; (c) rest in the open air, all the 
time if the patient is febrile, and at least a portion 
of the time if afebrile; (d) proper disposal of the 
sputum to avoid reinfection; (e) combatting all 
symptoms or conditions which interfere with the 
main treatment. 

Whether the treatment should be conducted in a 



TREATMENT in 

sanatorium, at one's home, or elsewhere in an open 
resort, must be decided by individual conditions, 
such as the domestic and pecuniary circumstances, 
the character, temperament, age, and the opportun- 
ity of securing competent medical supervision. 
With some patients of weak will, and in an indul- 
gent family, it would be well nigh hopeless to prose- 
cute the treatment with success at home. Although 
the essentials of the treatment are simple and few, 
they must be rigorously adhered to, and the patient 
must be where this can be done. 

Sanatorium or Outside Treatment 

On the other hand, one should not off-hand 
advise the sanatorium for every case, for not every 
patient, for one reason or another, is suitable for 
institutional treatment, and some will not go and 
others cannot. For the majority of patients, how- 
ever, a good sanatorium probably offers the best 
chances. If the physician and patient decide upon 
the sanatorium, they should be assured that its 
equipment, management, and medical direction are 
satisfactory; and of especial importance is the char- 
acter and skill of the physician in charge. Excel- 
lent results have been and can be obtained in an 
open resort, like Saranac Lake or Asheville, or at 
one's home, if the services of a skilled physician are 
at hand; for the constant supervision of a compe- 
tent physician is one of the prime essentials of the 
treatment. 



ii2 PULMONARY TUBERCULOSIS 

Rest in Febrile and Afebrile Cases 

For the first two or three weeks at the commence- 
ment of the treatment, every patient should be kept 
at rest, whether or not he is febrile, in order that 
an accurate estimate of his condition may be ob- 
tained and his future plan of treatment be deter- 
mined. Such rest is also of much value to the 
patient in enabling him to get a " start." If the 
patient is febrile, i.e., has an afternoon temperature 
of 99.5 F. or over, accompanied by constitutional 
symptoms, indicating active toxaemia, he should be 
confined strictly to bed, under exactly the same con- 
ditions as with a typhoid fever patient, " as com- 
pletely immobilized as possible." No exercise is 
to be allowed until the temperature becomes and 
remains normal. Exercise is only permissible when 
the patient is afebrile and free from all constitu- 
tional symptoms. With febrile patients sometimes 
the cough, which means severe exercise of the res- 
piratory muscles, is so troublesome and harassing 
that it interferes with proper rest, and something 
may have to be done to alleviate it. Usually, the 
open-air life suffices; if not, either some simple sed- 
ative may be employed, or, as a last resort, some 
of the milder preparations of opium, such as the 
following : 

Heroin grs. ii (0.13) 

Syr. tolu. 

Aquae distill, aa § ii (60.) 
TTt Sig. 3i t.i.d. 




Fig. 12. Inexpensive sleeping balcony in a country hous 




Fig. 13. Sleeping tent on roof (case in Boston) 



TREATMENT 113 

^ Dionin grs. v (0.32) 

Aquae amyg-d. amar §iss (45.0) 

Aquae ad §iii (90.) 

TTL Sig. 5i t.i.d. 

Or dionin % gr. tablets, or heroin %4 to %2 gr. 
tablets. These should be discontinued, of course, 
on the amelioration of the cough. If the temper- 
ature is not above 99 °, rest should be enjoined but 
not necessarily bed rest. 

The Out-Door Life 

The first requisite in the treatment is the pro- 
vision for the out-door life, both by day and night. 
Some kind of a sleeping porch can generally be 
devised, a piazza utilized, or a tent or simple struc- 
ture in the yard or on the house top, arranged for 
the out-door sleeping. 1 (Figs. 12-18.) 

Occasionally it will be found that one cannot 
sleep well out of doors; he is nervous, and is un- 
able to keep comfortably warm. Under these cir- 
cumstances, a well ventilated room with open win- 
dows is preferable. In the colder months of the 
year one should wear warm night clothes with 
woolen socks and have sufficient light bed covering, 
or a sleeping bag, and, if needed, a heater for the 
feet. A simple device for preventing the heat of 
the body from escaping below, and keeping out the 

C 1 The reader is referred to " Fresh Air and how to use It " 
by Carrington, published by the National Association for the 
Study and Prevention of Tuberculosis, 1912, for many val- 
uable suggestions and illustrations with reference to out-door 
sleeping.) 



ii4 PULMONARY TUBERCULOSIS 

wind, is several layers of newspaper placed under 
the mattress, or between two mattresses. If a 
piazza is used for out-door sleeping, some protec- 
tion from the wind should be afforded. One should 
dress and undress in a warm room. If the morning 
light awakens one too early, a shield for the eyes 
can be used, and about as good as anything for this 
purpose is a long black stocking loosely tied over 
the eyes. The habit of out-door sleeping is soon 
formed, and the sleep is so much more refreshing 
that one rarely desires to return to in-door condi- 
tions. With febrile cases, where one is in bed all 
the time, either the out-door sleeping porch or a 
well-ventilated room with open windows can be em- 
ployed, preferably the former. 

By day, during the rest periods, one can sit on 
the piazza, in the yard or on the house top, wherever 
the air is free and there is sunshine. During the 
cold weather, he must be well protected, both as to 
inner and outer clothing. A fur coat is the best 
outer covering; and woolen stockings, with high 
arctics, felt shoes, or sheepskin moccasins will keep 
the feet warm. A reclining chair, such as a ship's 
deck chair, is preferable; or, if an ordinary chair is 
used, a common soap box into which the feet are 
placed will protect them from the wind and cold. 
When very cold, a knitted hood can be worn on 
the head and fur gloves on the hands. Thus pro- 
tected, one can defy almost any temperature. 

While at rest out-of-doors one can either do noth- 
ing or occupy himself with some light handiwork, 




Fig. 14. Sleeping porch (Carrington) 



TREATMENT 115 

such as knitting, basket-making, light wood-work, 
simple games or reading. The effect of the con- 
stant open-air life is often very striking: the appe- 
tite and digestion are stimulated, weight is gained, 
sleep is sounder and more refreshing, nervous irri- 
tability disappears, and there is a general sense of 
well-being. 

The Food 

The nourishment of the patient should receive 
the most careful attention, and should be adapted 
to each individual case. If the appetite and diges- 
tion are normal and the patient is not much under 
weight, three liberal meals a day with the addition 
of milk will generally be sufficient. A mixed diet, 
as in health, is the desirable one, consisting of the 
proper proportions of proteids, carbohydrates and 
fats: of the proteids, from 500 to 700 calories; of 
the carbohydrates, 1200 to 1500 calories; and of the 
fats, 1300 to 1500 calories. If an increase in the 
amount of fats is indicated, these can be given in 
the form of butter, cream, olive oil, and other ani- 
mal and vegetable fats. 

The food should be varied, well cooked, and 
served, so as to be attractive and appetizing, and it 
should be taken at regular times. If the patient is 
much under weight or cannot eat a full meal, sup- 
plementary meals or simple lunches can be taken 
between the regular meals, consisting of milk and 
eggs, bread and butter, broths, cocoa, or other 
simple nutritious nourishment. If milk in its 
natural state is distasteful or causes digestive dis- 



n6 PULMONARY TUBERCULOSIS 

turbances, it can be modified in various ways : some 
alkali, as lime water, Apollinaris, or Vichy water 
may be added ; it can be peptonized, or mixed with 
the malted milk preparations, or taken in the form 
of kumiss, buttermilk, gruel, junkets, whey, etc. 

Very often it will be found that more or less 
anorexia and digestive disturbances exist, in which 
event special dietaries will have to be arranged and 
the appropriate means taken to correct the dyspeptic 
symptoms. Constipation is one of the most com- 
mon complaints, and it should be relieved, if pos- 
sible, by means of the diet : stewed prunes, made 
more laxative by cooking them with senna leaves; 
stewed onions, rhubarb, laxative fruits and vege- 
tables, cream or more fat of other kinds are useful 
for this purpose. A glass of warm water before 
meals is another expedient. If these measures do 
not avail, some of the simpler laxatives may be em- 
ployed, such as the purified liquid petroleum, cas- 
cara sagrada, or one of the laxative waters or salts. 
Sometimes special diets or food preparations may 
be required for a while, but every effort should be 
made to return to the ordinary mixed diet as soon 
as possible. 

The physician cannot be too painstaking in super- 
vising the diet of the consumptive patient as to qual- 
ity, quantity, the proportions of the food constit- 
uents, proteids, carbohydrates and fats, and the 
preparation, for " the consumptive who does not 
eat is a consumptive lost." No perfection of the 
open-air treatment will avail unless the patient is 




Figs. 15, 16. Simple sleeping porches (Carrington) 



TREATMENT 117 

well nourished. Rest before and after meals, 
especially the noon meal, should be the rule. The 
teeth must be kept in order and clean, for " well 
masticated is half digested." Before meals the 
mouth should be cleaned with some mild antiseptic 
solution, and after meals the teeth should be 
brushed. 

Suggestive Articles of Diet 

(All food must be properly cooked and well served) 
The following suggestive articles of diet will be 
a useful guide : 

Beef (rare) roast; steak; mutton (roast), chops; 
fowl; bacon; good sausages; minced meat; cold 
meat and fowl; sweetbreads; eggs (raw, poached, 
boiled). Vegetables, such as, baked potatoes, peas, 
string beans, spinach, asparagus, etc. Fish; soup 
(thin at dinner). Bread and butter, rolls, corn 
meal bread, rye bread. Cream or milk toast; ce- 
reals with cream and sugar. Soft boiled rice with 
cream. Farinacious puddings; ice-cream. Cheese. 
Salads, with oil dressing; sauces in which butter is 
the principal ingredient. Fruit, raw or cooked, as 
baked apples, stewed prunes, marmalade. Oat- 
meal gruel. Coffee (moderate), tea, cocoa, milk. 
(A glass or more of milk at each meal, and between 
meals, if ordered.) Good water plentifully taken 
at and between meals. 

Exercise 

All febrile patients, as has been said, must be 
kept absolutely at rest, and all afebrile patients must 



n8 PULMONARY TUBERCULOSIS 

have periods of rest, especially when the vitality is 
low and the patient is under weight. There comes 
a time, however, when some exercise is allowable 
and beneficial; but it must be prescribed by the 
physician as to the kind and amount, and carefully 
supervised. The condition which permits exercise 
is that in which the patient is free from fever and 
constitutional symptoms ; when the active stage of 
the disease has passed and he is on the road to 
an " arrest." The supreme test that exercise is 
beneficial and not harmful is the absence of any 
rise of temperature or increase of pulse rate a half 
hour or an hour after the exercise, and of any con- 
stitutional disturbance, such as headache, lasting 
fatigue and a general feeling of weakness and ma- 
laise. When these symptoms occur, all exercise 
should be intermitted for several days. Walking is 
the best form of exercise to begin with, taken on 
the level at first, and, later, on very gradual ascents. 
The length of the walk must be definitely deter- 
mined by the physician. Various other forms of 
exercise or work, such as can be gradually increased 
from a little and light to a longer period and more 
severe, can be engaged in. To ensure success and 
avoid mishap, all work should be carefully graded, 
going on from step to step. The patient's condi- 
tion, tastes and circumstances will often suggest the 
especial form of exercise. It may be some useful 
employment, such as light farm work, gardening, 
book-binding, or a limited amount of house work 
for women. 




Fig. 17. The Dunham bed, showing how head may project out 
of window 




Fig. 18. The Millet Sanatorium at East Bridgewater. Shack 
used for treatment of tuberculosis 



TREATMENT 119 

In determining the time to begin exercise in the 
course of the treatment, each individual case must 
be considered by itself. In general, we can say that 
exercise is beneficial at that stage of the disease 
when the strength and weight have increased, and 
there is no fever or other symptoms indicating 
toxemic activity. The proof of benefit from the 
exercise is continued improvement in the general 
condition. When the proper time comes for exer- 
cise, it should be begun as an integral part of the 
treatment, for when the recovery is achieved, the 
patient should be ready to again take his place in 
life's activities. 

Violent forms of exercise, such as horseback 
riding, tennis, dancing and rowing are unsafe. 
Golf, however, is allowable, and it has the advan- 
tage of being easily graded, as one can be given 
only a certain number of holes to play. Gymnastic 
and breathing exercises are of doubtful value and 
may do harm, and it is safer not to employ them. 
If there is doubt regarding the question of exercise, 
it is well to remember that no harm can be done 
by rest, but that " more consumptives kill them- 
selves by taking too much exercise than in any 
other way." 

Clothing 

Little need be said upon this subject. Such 
clothing should be worn as will make the patient 
comfortable and no more. The clothing should be 
evenly distributed over the body, and no greater 
thickness, such as chest protectors, vests or sweat- 



120 PULMONARY TUBERCULOSIS 

ers, should be worn over the chest than elsewhere. 
Too heavy clothing only overburdens one and causes 
him to perspire more easily ; generally, however, the 
patient is rather more susceptible to cold and needs 
to dress a little warmer than in health. Light 
woolen or merino underclothing is advisable and 
should be loose enough to permit a circulation of 
air beneath it. The undergarments worn during 
the day should be removed at night and thoroughly 
aired, and they should also be changed if one gets 
overheated and perspires. For out-door use in 
winter a fur coat is the warmest. 

The Cold Bath 

A warm soap bath for cleanliness should be taken 
once or twice a week and in addition a cold sponge 
or shower bath in the morning on getting up if a 
speedy reaction occurs thereafter. If, on the con- 
trary, there is a failure to react, as indicated by 
chilliness, lasting a considerable time, after the bath, 
blueness, " goose-flesh," and a feeling of depression 
instead of one of invigoration, the bath should be 
abandoned or milder hydrotherapeutic measures em- 
ployed until one is able to endure the more rigorous 
form. The cold bath is a hardening process, its 
object being to stimulate the peripheral nerves, in- 
crease the appetite, improve nutrition and assimila- 
tion, and to produce an invigorating effect on the 
body as a whole. The temperature of the water 
should be from yo° to 6o° F. or even 55 . Simple 
means can easily be obtained for taking the cold 



TREATMENT 121 

bath. All that is really requisite is a tub of some 
kind, a large sponge and a coarse towel. Salt may 
be added to the water to increase its stimulating 
effect. One saturates the sponge with water, and 
squeezes out the whole amount in a shower down 
the back and front, as he stands in the tub; this 
procedure is rapidly repeated over all parts of the 
body for about half a minute; he then rubs him- 
self dry with the coarse towel. Instead of the 
sponge, a pitcher of water. can be poured over the 
body, or a hose with a spray attachment can be 
connected with any convenient faucet in the house. 

With some patients, one has to begin gradually 
and work up to the cold bath : at first, with dry rub- 
bing morning and night; later, with moist rubbing 
by means of a wet, coarse cloth or by enveloping the 
patient in a wet sheet and rubbing him over it, until, 
finally, the stage of the ordinary cold bath is 
reached. If there is a tendency to hemorrhage, 
there is danger in the cold bath and it should be 
omitted. 

The Psychology of the Patient 

It is obvious that tranquillity of mind and con- 
tentment are essential in order to realize the best 
results from the treatment. " The consumptive 
must be treated in toto," says Dettweiler, " and his 
moral and mental education is quite as important 
as his bodily treatment." To secure this, much de- 
pends upon the personality of the physician ; he must 
be able to inspire his patient with hope and courage. 
Everything which has a tendency to produce nerv- 



122 PULMONARY TUBERCULOSIS 

ous and mental excitement, such as domestic or 
financial worry, or exciting literature, should be 
sedulously avoided. Some simple, soothing di- 
version is often of assistance in distracting the 
patient's thoughts from his malady. Such are 
games of solitaire, simple, light occupations, like 
knitting, raffia work and the like, or an amusing 
story. Music is one of the best means of soothing 
and diverting the patient. I recall a visit to a Ger- 
man sanatorium where one of the features was a 
band concert several times a week. 

" When griping grief the heart doth wound, 
And doleful dumps the mind oppress, 
Then music with her silver sound, 
With speedy help doth lend redress." 

Often a talk with the physician will relieve a de- 
pressed patient and inspire him again with hope. A 
firm religious faith is a precious asset, yielding that 
peace of mind and restfulness of spirit which 
" passeth understanding." 

Personal Hygiene 

The consumptive must maintain absolute clean- 
liness. The hands should be washed before each 
meal, the mouth cleansed, and the nails kept well 
manicured. The sputum should never be swal- 
lowed, and none should be allowed to soil his body 
or bed clothes or anything he handles. When 
coughing, one should hold something before the 
mouth. Any carelessness in disposing of the 
sputum may cause a reinfection or the infection of 



TREATMENT 123 

some one else. If a mustache or beard is worn — 
which is not advised — this should be washed sev- 
eral times daily. In brief, everything on and about 
the patient, or used by him, should be kept scrup- 
ulously clean. 

Osier's Summing Up 

Osier thus succinctly and admirably expresses 
the sum and substance of the treatment : 

" First : The confidence of the patient ; since 
confidence breeds hope." 

" Second : A masterful arrangement on the part 
of the doctor." 

" Third : Persistence. Benefit is usually a mat- 
ter of months; complete arrest a matter of years." 

" Fourth : Sunshine by day ; fresh air night and 
day." 

"Fifth: Rest while there is fever." 

" Sixth : Breadstuff's and milk, meat and eggs." 

The following is an illustrative daily plan of life 
for an afebrile patient of fair resistance and with 
few if any constitutional symptoms: 

7 A. m. Arise ; a cold sponge or shower bath. 
Dress in a warm room. 

7.30 or 8 a. m. Breakfast, and afterwards rest 
in a reclining chair, or a walk or other exercise if 
prescribed. 

11 a. m. A light lunch, if ordered, consisting of 
a glass of milk and egg, or some simple articles of 
food. 

12 u, to 1 p. m. Rest. 



124 PULMONARY TUBERCULOSIS 

i to 1.30 p. M. Dinner. 

1.30 or 2 p. m. Rest for an hour; later, a walk 
or other exercise. 

4 p. m. A light lunch if ordered. 

4 to 6 p. m. Rest or exercise as prescribed, but 
a half hour's rest before the evening meal. 

6 p. m. Supper. 

6.30 to 9 p. m. Simple recreation of some kind 
or rest. 

9 p. m. Retire. 

Of course the daily routine must obviously be 
arranged according to the special conditions of each 
individual. 

" Suggestions and Aids " 

I have been accustomed to hand the following 
brief suggestions to my patients, based largely upon 
similar ones devised by Dr. Minor of Asheville : 

(These suggestions are general and not intended 
to take the place of the physician's advice for your 
special condition.) 

" The labor which best repays a sick man is to get 
well." 

If treatment is begun early most cases of tuber- 
culosis can be cured, but it requires determination, 
perseverance, and often self-denial to accomplish it. 

There are four (4) essentials in the treatment : 
(1) Competent medical guidance; (2) fresh air; 
(3) good food; (4) rest. There are no known 
medicines or specifics which will cure tuberculosis, 
therefore, do not take any drugs except what may 



TREATMENT 125 

be ordered by your physician for certain special 
symptoms. 

Whether the treatment in your case can be best 
carried out in a sanatorium, at home, or by going 
to a health resort, must be decided by your phy- 
sician. 

Most patients must devote their entire time to 
getting well, at least in the beginning of the treat- 
ment, for it requires constant attention to learn and 
become accustomed to the new method of living, 
which we call the " open-air " treatment, or the 
"cure." 

Rest 

Rest is very important in the " cure," and, if 
there is fever — a temperature of 99.5 ° or over — 
it should be absolute, and you should recline on a 
cot or reclining chair out-of-doors, or in bed with 
windows wide open. Even if there is no fever, you 
should spend a good deal of time at rest, especially 
at the beginning of the treatment. You can do 
this by sitting or reclining on a piazza or wherever 
fresh air can be obtained and protection from the 
wind secured. 

The Outdoor Life 

After the habit has been formed you should spend 
from seven to ten hours out-of-doors daily, winter 
and summer. When it is cold, dress warmly and 
use sufficient wraps to be comfortable. Keep in 
the sun, but protect the head from it. The out- 
door life can be continued at night by sleeping out- 



126 PULMONARY TUBERCULOSIS 

of-doors, either on a piazza, in a sleeping porch, or 
by using a window tent. Night air is as good as 
day air, and sometimes better. In sleeping out- 
of-doors, you must have sufficient covering and 
warm night clothes, a flannel nightdress, or pajamas, 
woolen stockings, a Jersey or " sweater," a woolen 
hood or helmet, and a hot water bottle or soap 
stone, if necessary to keep warm. If you sleep in 
a room, have a large one with two or more win- 
dows, facing South, Southwest, or Southeast, and 
if possible, with an open fireplace in it. When in 
the room and not in bed have the temperature from 
65 to 68, unless dressed as for out-of-doors. Dress 
and undress in a warm place. Sleep alone, and if 
possible occupy the room alone. Have the room 
plainly furnished with few things in it, so that it 
can be easily cleaned and kept clean. Go to bed 
early, at 9 or 9.30 p. m. 

Clothing 

Wear such clothing as will keep you warm, but 
not such as will be a burden to carry about and 
cause you to perspire at any little exertion. Wear 
wool or merino next to the skin. Do not wear 
" chest protectors." Woolen stockings and low 
shoes will often keep the feet warmer than cotton 
stockings and boots. For outdoor use an ulster or 
fur coat is very serviceable. If you get overheated 
and perspire change the clothes and rub the skin dry. 
Never be chilly. 



TREATMENT 127 

Bathing 

Take a warm bath once or twice a week at bed- 
time. A cold sponge bath on getting up in the 
morning, as ordered by the physician. If you do 
not react, or feel chilly after the cold bath, or feel 
sick in any way, stop the bath and consult your 
physician. Take the cold bath in a warm room. 
If you have night sweats take a rub with vinegar 
and water at night, and a glass of hot milk. If you 
are frequently chilly, take an alcohol rub. 

Food 

If the digestion is good, eat three good meals a 
day, consisting of soup, meat, vegetables, bread and 
butter, milk, cream, eggs, articles of food contain- 
ing fat or prepared with fat or oil, fruit, etc. Your 
physician may also order in addition to the three 
meals simple lunches at 11, 4 and bed-time, con- 
sisting of milk, raw eggs, bread and butter, cocoa, 
chocolate, soup, etc. Do not eat cake or pastry. 
Rest an hour before and be quiet an hour after 
meals. Eat slowly and chew the food thoroughly, 
therefore, see that your teeth are in good condition. 
Drink the milk slowly or sip it. If you think you 
are overeating from any feeling of distress after 
meals, or from any indication of indigestion, con- 
sult your physician. The food must be abundant, 
nourishing, and prepared in an appetizing manner. 
Your salvation lies in food, properly prepared, and 
in a stomach capable of digesting the food. Be 
regular at your meals and try to enjoy them. Eat 



128 PULMONARY TUBERCULOSIS 

with others, and converse with others, rather than 
eat alone. Have your physician prepare a bill-of- 
fare for you. Drink pure water, and never take 
alcoholic stimulants unless prescribed by your phy- 
sician. 

Cough and Expectoration 
Never spit anywhere except in a cuspidor with 
water or a disinfectant in it, or in a spit-cup, pocket 
spitoon, or a paper napkin which then can be put 
in a paper bag and burned. The best way of de- 
stroying the sputum is to burn it. In coughing, 
hold a cloth or paper napkin before the mouth ; if a 
handkerchief is used, do not let it get dry, and wash 
it in boiling water. Ineffective coughing — that 
which does not bring up sputum — is useless, tire- 
some, and renders one conspicuous. Therefore, try 
to control and repress such a cough, which you can 
do by practice. Never swallow the expectoration, 
as it may cause further infection. Always wash 
you hands before eating; clean your teeth, and wash 
out your mouth and nose several times a day. If 
any expectoration should, by accident, get on the 
floor, or on any article of clothing or furniture, it 
should be wiped up at once with soap and hot water, 
or with a five per cent, solution of carbolic acid. 
Whatever increases the cough, refrain from doing. 
A clean consumptive is a safe consumptive. 

Exercise 

In your own special case, follow the advice of 
your physician; in general, at the beginning of the 



TREATMENT 129 

treatment, it is usually best to keep pretty quiet. 
Never exercise if there is fever, if the temperature 
is over 99.5 °. Never to the point of fatigue. No 
exercise for an hour after meals, and none if the 
sputum is streaked with blood. No gymnastic or 
breathing exercise unless ordered by your physician. 
Walking is usually the best and safest exercise, at 
least until the " cure " is well advanced. No violent 
exercise or such as causes you to feel uncomfortably 
short of breath. 

Maxims and Random Hints 

When in doubt about anything, consult your phy- 
sician; take no chances. 

Do not talk over your case with any one but the 
doctor. 

A hemorrhage (spitting blood) is generally not 
a very serious symptom; if you have one, go to bed 
and keep very quiet and send for your physician. 

It takes time to make the " cure," so do not be 
impatient to get well; a good cure is often a slow 
cure. 

The instructions given you by your physician 
should be followed out in every particular. 

A person suffering from tuberculosis is not dan- 
gerous to live with if he promptly destroys the 
sputum and covers his mouth when coughing 

A hopeful, cheerful disposition is one of the best 
remedies for pulmonary tuberculosis. 

Your most important duty is to get well. Let 
all other duties be secondary. 



130 PULMONARY TUBERCULOSIS 

" Whatever thou takest in hand remember the 
end, and thou shalt never do amiss." 

" Whatever is worth doing is worth doing well." 
" Where sunlight enters not, there the physician 
goes." 

" It is part of the cure to wish to be cured." 
The important essentials in the treatment of your 
disease are: Out-of-door life, winter and summer, 
day and night. Have no fear of night air, and none 
of draughts, provided you are properly protected. 
Avoid damp houses or rooms, and crowds, smoke 
and dust. Avoid all excesses. Eat plenty of good, 
nourishing food. Drink plenty of good water, but 
no alcohol. Be careful not to exercise when you 
should rest. Take no drugs except on the advice 
of your physician. Keep the body clean. Never 
swallow the sputum. Be hopeful and cheerful. 

Special Directions of the Physician 

Take your temperature at 

Lunches at .,.,.... 

Consisting of 

Hours out-of-doors 

Exercise . . 

Bathing 

Day's Plan to be Filled Out by Your Physician 

7 or 7.30 a. m 

7.30 or 8 a. m 

8.3O tO II A. M ,. ., , 

II A. M 



TREATMENT 131 

II,30 A. M. to I P. M 

1 tO 2 P. M 

2 tO 4 P. M , 

4 P. M 

4.30 tO 6 P. M 

6 to 7 P. M . .. 

7 to 9 or 9.30 p. m 

9 or 9.30 p. m ■. ..... ., 

Medicine, if any. 

Treatment of Advanced, Hopeless Cases 

The main thing to be done for these deplorable 
cases is to make them physically comfortable, and 
everything which conduces to this should be allowed. 
Fresh air, they should have; but unless they desire 
it, they should not be exposed to the rigors of out- 
door life in the colder season of the year. A com- 
fortable bed in a well ventilated room is generally 
preferable. All the innumerable symptoms con- 
stantly complained of or imagined should be met 
with kindly attention and patience. If pleuritic ef- 
fusion occurs, as it not infrequently does, it is not 
to be aspirated unless there is immediate danger of 
a fatal result, or it causes great distress. Some- 
times the effusion renders the patient more com- 
fortable or tends to retard the disease on the same 
principle as artificial pneumothorax. If the cough 
is harassing and prevents sleep, codein, heroin or 
dionin may be used, or sometimes the mild tincture 
of opium (tr. opii comp.) acts admirably. 

The diet should be simple and easily digestible, 



132 PULMONARY TUBERCULOSIS 

such as milk and milk preparations, broths, custard, 
milk toast, etc. Anything which the patient de- 
sires and which does not distress him may be al- 
lowed. 

If dyspnoea is a marked symptom, as it often is, 
besides absolute rest in a comfortable position, re- 
lief may be obtained from some of the diffusible 
stimulants, such as the aromatic spirits of ammonia, 
" Hoffman's anodyne," champagne, or the inhala- 
tion of oxygen gas. Strychnia is also of value for 
this condition. Generally, opium in some form will 
have to be pretty constantly employed, as it is, per- 
haps, the one best reliance for such cases. 



CHAPTER VIII 

ESPECIAL METHODS OF TREATMENT 

" All methods of treatment end in disappointment of 
those extravagant expectations which men are wont to 
entertain of medical art." 

0. W. Holmes. 

Various anti-tuberculosis serums and innumerable 
drugs and special methods of treatment have been 
and still are brought forward by their enthusiastic 
advocates, as exercising a specific influence upon 
tuberculosis, either by their inhibitive or destructive 
influence upon the tubercle bacillus and its toxins, 
or by their influence in promoting the formation of 
fibrous tissue, such, for example, as creosote, arsenic, 
mercury, iodine, the alkaline hypophosphites, raw 
meat and raw meat juice, and many others. None 
of these " short-cut " methods of arresting the dis- 
ease, however, has proved of any specific value, 
and, from the nature of the disease, probably no 
specific ever will be discovered. There are two es- 
pecial methods of treatment used in connection with 
the usual hygienic-dietetic measures which have 
established themselves as of more or less value in 
selected cases by long experience and observation. 
They are tuberculin and artificial pneumothorax. 
133 



134 PULMONARY TUBERCULOSIS 

Tuberculin 

Tuberculin, first originated by Koch, is the pro- 
duct derived from cultures of the tubercle bacillus, 
either in the form of the filtered extract of the 
bacillus, containing its dissolved toxic products, as 
in Koch's old tuberculin (O. T.), or it may be com- 
posed of the pulverized insoluble substance of the 
bacilli themselves, the " bacillen-emulsion " of Koch. 
There are very many tuberculins depending upon 
the various methods of preparing them, but they are 
all essentially the same and act in the same way. 
Probably Koch's old tuberculin, (O. T.), and his 
bacillen-emulsion, "new tuberculin" ("B. E.") 
are the most frequently employed in the therapeutics 
of tuberculosis, although each variety has its ad- 
vocates. Whatever the method of production em- 
ployed, or the exact composition of the tuberculin, 
it contains, of course, no living tubercle bacilli. 

The theory of the action of tuberculin is that 
active immunity is produced, — not immunity to the 
tuberculosis, as anti-diphtheritic serum does to 
diphtheria, — that is, passive immunity; but a stim- 
ulation of the defensive powers of the body is pro- 
duced, and more anti-bodies are formed to contend 
with the toxins of the bacilli. The action of tuber- 
culin is solely towards the specific infection, and 
it has no effect upon a healthy person. It is not a 
cure, only in properly selected cases it may be said 
to be a favorable factor, how favorable we cannot 
say. 

Trudeau, the famous physician of Saranac Lake 



METHODS OF TREATMENT 135 

in the Adirondacks from his long and extensive 
experience, thus conservatively states the case: 
" My experience with the tuberculin treatment 
thus far has led me to believe that when care- 
fully applied in suitable cases, it has seemed to have 
some favorable influence in bringing about healing 
of the lesion." 

The suitable cases for the use of tuberculin are 
those in which there is a fair degree of resistance 
and in which the general condition is good, and in 
this class are included (a) early cases with small 
local lesions; (b) moderately advanced cases which 
have remained stationary under the usual hygienic- 
dietetic treatment; and (c) cases in which the phy- 
sical signs are extensive, but with slight constitu- 
tional symptoms. Mild fever is not a contraindica- 
tion if the nutrition is good. The fundamental con- 
dition in all cases for the use of tuberculin is that 
there should be a fairly good resistance; otherwise, 
the tuberculin will do harm. Tuberculin can be 
safely employed in ambulant cases, as is done in 
many clinics, and in the doctor's office; but the 
patient must be perfectly able to come to the dis- 
pensary or office. 

The technique of the tuberculin treatment is now 
easy, since the proper dilutions can be readily ob- 
tained from reputable firms. The main point to 
bear in mind is to begin with small doses and in- 
crease so slowly that no reaction occurs. Having 
selected the tuberculin to be used, for instance, 
Koch's old tuberculin (O. T.), one begins with a 



136 PULMONARY TUBERCULOSIS 

dose of o.ooo.oooi c.c. to 0.000,001 c.c. and gradu- 
ally increases it by twice the first dose, then three 
times, four times, etc., the first dose, until finally the 
maximal dose of 1.0 c.c. is reached, which is usu- 
ally in about six months. The intervals between the 
doses is generally three or four days, and this in- 
terval is maintained as long as the patient is doing 
well. If, however, a slight reaction should occur, 
the interval should be increased to one week, and 
the dose diminished. A subcutaneous syringe grad- 
uated in tenths of a c.c. is employed, the dose being 
so many tenths of a c.c. of the dilution used. The 
injection is preferably given in the back at the angle 
of the scapula, and the usual antiseptic precautions 
observed. If a reaction occurs, it is indicated by 
a rise of temperature, a loss of weight, headache, 
and general malaise, a focal reaction by changes in 
the pulmonary signs, and, locally, by pain, tender- 
ness or swelling at the site of injection. Of the 
general reaction, the most important signs are fever, 
loss of weight and general depression. 

If the tuberculin treatment is successful, it is in- 
dicated by an improvement in the appetite and diges- 
tion, increase in strength and usually in weight. 
Other evidence of improvement may also be noted. 

When the higher doses are reached, the intervals 
can be longer, from two to four weeks. There can, 
obviously, be no fixed doses, as the resistance of 
the patient is an uncertain factor. Each one must 
be individualized, both as to the dose and as to its 
increase. 



METHODS OF TREATMENT 137 

The main object to be attained in the tuberculin 
treatment is to gradually increase the tolerance to 
it to the highest point attainable, avoiding reaction. 
It is well again to repeat that tuberculin is not a 
cure, but only a favorable factor in certain cases, 
and it does not by any means take the place of the 
hygienic-dietetic treatment, but is only to be used in 
connection with it. With ordinary care and con- 
stant supervision of the patient, tuberculin used ac- 
cording to the above precautions can with safety be 
used by any physician. 

Artificial Pneumothorax 

Artificial pneumothorax, as its name implies, is 
the production of a pneumothorax in the pleural 
cavity of the diseased lung for the purpose of col- 
lapsing the lung, and it is accomplished by injecting 
air or nitrogen gas, generally the latter, into the 
pleural space. The object to be attained is the 
immobilization of the lung, the promotion of the 
formation of connective tissue, the collapsing of 
cavities, and a reduction of toxic absorption. It is 
applicable to only a limited number of cases, chiefly 
to those in which there is extensive unilateral (or 
chiefly so), progressive or chronic disease which 
fails to respond to the ordinary hygienic-dietetic 
measures. It has also been successfully employed 
in recurring or very severe hemorrhages which 
failed to yield to other treatment, provided, of 
course, it was determined from which lung the hem- 
orrhage came. 



138 PULMONARY TUBERCULOSIS 

Artificial pneumothorax is, in one sense, a last 
resort in that it is chiefly applicable to those cases 
which, under any other treatment, seem doomed; 
and experience has shown that many such cases 
have been saved by it. This operation has also been 
recommended and, indeed, employed in earlier cases 
which appeared to have no recuperative power or 
showed no improvement under the ordinary meas- 
ures of treatment. In far-advanced cases it has 
occasionally produced an arrest of the disease, or 
an amelioration of the symptoms. The cases of 
choice, however, are those chiefly or entirely uni- 
lateral when there is still a fair amount of resistance, 
and such cases are comparatively few. 

It is not always possible to induce a pneumothorax 
on account of pleural adhesions. 

The operation in one sense is a simple one, so 
far as the operation itself is concerned, but it re- 
quires much experience and careful manipulation 
in order that the lung may not be punctured and 
gas injected into the circulation, producing gas em- 
bolism. It is also quite essential that one should 
possess the knowledge which the X-ray picture of 
the chest gives, so as to select the most favorable 
site for the puncture and to determine the condition 
of the pleura as to adhesions, and subsequently to 
note the effect of the injection, to be sure the gas 
is in the pleural cavity and to see how far the col- 
lapse has advanced. A special apparatus is also 
necessary, with a manometer to indicate by the 
oscillation of the fluid in it whether or not the needle 




Fig. 19. Dr. Samuel Robinson's apparatus for artificial 
pneumothorax 




Fig. 20. Illustrates a needle which Dr. Cleaveland Floyd has 
designed 

Kindness of Codman & Shurtleff, Inc., 120 Boylston St., Boston, Mass. 



METHODS OF TREATMENT 139 

is in the pleural cavity, and also the pressure. 
(Figs. 19, 20.) The operation is performed under 
careful antiseptic conditions and for the first weeks 
of treatment the patient as a rule should be kept 
quiet in bed. Local and anaesthesia alone is re- 
quired. The following solution being used : 



9 




Novocaine 


0.5 


Adrenalin 


1.0 


TTL Aquae distill. 


100. 



Or eucaine with adrenalin may be employed for 
the same purpose. Of the novocaine solution 
thirty minutes is generally sufficient. Not only the 
superficial parts but the pleura itself should be 
anaesthetized. Although the general physician will 
usually refer the cases he thinks suitable for artificial 
pneumothorax to the expert, still he should know 
something about the operation and its effects, as 
well as what class of cases is likely to be benefited by 
it, in order that he may intelligently advise his 
patient. 

If the first application succeeds and one feels sure 
he is in the pleural cavity, 200 to 300 c.c.'s of the 
nitrogen gas are injected and in a day or two the 
same amount or more, until gradually the lung is 
more or less fully collapsed. 

As has been said above, the patient should be kept 
quiet for several weeks until the changed conditions 
in the circulation from the pressure have adjusted 
themselves. Later, he can be up and, possibly, come 



140 PULMONARY TUBERCULOSIS 

to the clinic or office for the refillings which need 
only to be done at quite long intervals after col- 
lapse has once been well established. Compression 
should be maintained for a long time, — a year or 
more. 

If the operation is effective, the result is shown 
in a decrease of the temperature and pulse rate, dis- 
appearance of night sweats, improved appetite and 
digestion, and a general feeling of well-being. The 
cough and expectoration may at first be increased, 
but after a few days decrease and may entirely dis- 
appear. 

So far as danger is concerned in the operation 
itself, one can say that, in skilled hands, if a careful 
technique is observed, it is practically free from 
danger; so that if it does no good, it will do no 
harm. 

The evidence now at hand abundantly proves the 
value of artificial pneumothorax as an additional 
weapon in the treatment of tuberculosis. As Prof. 
Saugman says : " It has fully justified its place 
in the treatment of some severe cases of pulmonary 
tuberculosis, and, that by it, recovery sometimes may 
be obtained when any other treatment would have 
failed." 



CHAPTER IX 

TREATMENT OF SPECIAL SYMPTOMS 

" ' Fortune always leaves some door open in disasters, 
whereby to come at a remedy,' said Don Quixote." 

" The means that heaven yields must be embrac'd 
And not neglected; else if heaven would, 
And we would not, heaven's offer we refuse." 

Richard II, Act III, Sc. 2. 

Debility, Anorexia and Loss of Weight 

One of the prominent and early symptoms of pul- 
monary tuberculosis is debility, often accompanied 
by loss of weight. The first and most important 
step in the treatment of this condition is rest in the 
open air and proper and abundant food, rich in 
proteids and fats. It will often be found that a 
patient can take and digest a larger amount of food 
than in health if properly prepared and made ap- 
petizing, but it may have to be given in small 
amounts at frequent intervals. It is well in this 
connection to remember the saying of Dettweiler, 
" My kitchen is my pharmacy." One cannot give 
too much attention to the food question of his con- 
sumptive patient. 

If the appetite is wanting, some of the bitter 
tonics may be employed, such as nux vomica, gen- 
141 



142 PULMONARY TUBERCULOSIS 

tian, calumba, cardamom, cinchona, often combined 
with advantage with the mineral acids or Italian 
vermouth. Again, the compound syrup of hypo- 
phosphites, or some of the malt preparations will 
be of assistance. The following is recommended 
by Burton Fanning as particularly useful, both in 
stimulating the appetite and remedying various di- 
gestive disturbances, such as flatulence and disten- 
sion: 

Sodii bicarb. grs. xv (i.o) 

Tr. nucis vomicae mvii (0.4) 

Tr. gentianae 3ss (2.0) 

Aquae chloroformi ad §i (30.0) 
TH, Sig. The above at a dose before meals. 

Constipation, if present, must be corrected by 
food or laxatives, as has been previously indicated, 
and digestive disturbances counteracted by appro- 
priate treatment as will later be considered. 

Anaemia 
As a matter of routine, the blood should be ex- 
amined both as to the percentage of hemoglobin, 
and the number of red blood-corpuscles. If evi- 
dences of anaemia are found — the secondary 
anaemia of tuberculosis — in addition to nourish- 
ment and fresh air, iron in some form is indicated. 
One can either employ some of the older prepara- 
tions, such as the chlorid and carbonate of iron or 
the syrup of the iodid, or one of the many new prep- 
arations, such as ferro-mangan, ovoferrin, pro- 



SPECIAL SYMPTOMS 143 

It is also to be remembered 
that a diet rich in iron, such as the yolk of an egg, 
whole wheat, red meat, green vegetables, etc., may 
furnish the needed iron. 

Arsenic comes next in importance to iron in the 
drug treatment of anaemia, and here we may em- 
ploy either the simpler forms, such as arsenious 
acid %o gr. dose, or Fowler's solution, beginning 
with 3 or 4 drops and gradually increasing to 7 
drops; or some of the more complex preparations, 
such as sodium cacodylate % to 2 grs. in pills or 
hypodermically, which is considered less toxic than 
the ordinary preparations of arsenic and less apt to 
cause digestive disturbances. Sodium arsenate 
M.00 to %o gr. or elarson Vs gr. are other prepara- 
tions. Arsenic and iron can also be employed with 
advantage in combination, and can be given sub- 
cutaneously in the form of citrate of iron .05 and 
sodium arsenate .001 the injections to be given in 
the gluteal region or in the deltoid muscle twice a 
week. Iron arsenate Vie- 1 /^ gr. arsenoferratin 
7V2 grs, three or four times a day, and arsentriferrin 
5 grs. are other combinations. Strychnia, an ex- 
cellent nerve tonic, may also be combined with one 
or both of the other two drugs, as iron arsenate and 
strychnia, or citrate of iron .05, sodium arsenate 
.001 and strychnia .001, or citrate of iron .05 and 
strychnia .001, given subcutaneously. These com- 
binations for subcutaneous injection can be obtained 
in ampules. Hemaboloids arsenated with strychnia 
is said to be a favorable combination of the three 
drugs. 



144 PULMONARY TUBERCULOSIS 

Gastro-Intestinal Disturbances 

Digestive disturbances frequently occur in tuber- 
culosis and are to be treated according to the in- 
dications very much as in other diseased conditions. 
As it is of the utmost importance that the tuber- 
culous patient should efficiently digest and assimilate 
his food, careful and immediate attention should 
be given to any digestive irregularities. The main 
reliance should be upon a careful selection and prep- 
aration of the food. It may be necessary to have 
recourse to a test meal and examine the stomach 
contents, or investigate the dejections in order to 
determine the cause of the disturbance and the ap- 
propriate treatment. If constipation is present, that 
should be relieved. If the normal digestive fer- 
ments are defective in activity and deficient in 
quantity, some form of pepsin, either alone or in 
combination with hydrochloric acid or lime juice, to 
which some of the bitter tonics can be added, are 
indicated. If there is much fermentation and gas, 
such remedies as creosotal one or two drops, pan- 
creatin 5 grs., salol 5 grs., charcoal, spirits of 
chloroform, 20 minims to one fluid drachm, asa- 
fcetida 5 grs., or a brisk cathartic are to be em- 
ployed according to the indications. When there 
is gastric pain and distress after eating accompanied 
perhaps with nausea and vomiting, menthol 1 or 
2 grs. and bismuth with bicarbonate of soda are 
useful. In every case the diet must be carefully 
regulated ; fried and rich foods must be avoided and 
one may be obliged to have recourse to especially 



SPECIAL SYMPTOMS 145 

prepared food, such as milk with Vichy or Apol- 
linaris water, kumiss, beef juice, etc. 

When there is a general nervous condition coin- 
cident with the gastric disturbance, or perhaps its 
cause, Bonney x strongly recommends the following 
as of value from a long experience in its use: 

Strychnin %o gr. 
Salol 5 gr. 

Aqueous ext. of opium, Ko gr. 
Ext. cannabis indica Yi5 gr. 
Aloin %o gr. 
TTL Sig. The above to be taken in capsule after 
meals. 

Vomiting 

This is a serious symptom, as it often entails the 
loss of a meal, and thereby interferes with the 
nourishment of the patient. It is caused either re- 
flexively from the cough, or from irritability of 
the pharynx or from gastro-intestinal disturbance. 
Vomiting occurs frequently after breakfast, the tak- 
ing of food excites coughing, and the coughing re- 
sults in vomiting and the loss of the meal. To ob- 
viate this, a warm drink, such as a glass of milk, a 
cup of coffee or beef tea or Vichy or Apollinaris 
water is taken on awakening. The warm drink ex- 
cites the inevitable morning paroxysm of coughing 
and clears out the accumulated secretions, and later 
the breakfast can be safely taken. If the pharynx 

1 " Tuberculosis and Its Complications," Phila., 1908. 



146 PULMONARY TUBERCULOSIS 

is irritated, anesthesin, orthoform or novocaine can 
be applied locally. When there is gastric irritabil- 
ity anesthesin can also be employed internally, co- 
dein, oxalate of cerium or chloroform water. 

Diarrhoea 

Diarrhcea may occur in any stage of pulmonary 
tuberculosis, either from digestive disturbances or 
from a tuberculous involvement of the intestinal 
tract. In the latter case it generally occurs in the 
late stages of the disease. If from digestive dis- 
turbances, the principal indication is the regulation 
of the diet; for a day or two a milk diet or milk 
foods with toast may be all that is necessary, first 
cleansing the alimentary canal with castor oil or 
calomel. If medication seems indicated bismuth 
salicylate is perhaps the best remedy, a teaspoon ful 
of the powder taken with meals. Tannigen 3 to 10 
grs. (0.2 to 0.7) four times a day dry on the tongue, 
followed by a swallow of water or mixed with food, 
and tannalbin 15 to 60 grains (1.0 to 4.0) in 
powder or tablets followed by water or in gruel, 
are other useful remedies. In the diarrhcea of tu- 
berculous ulcerations the above remedies may be of 
avail; or others are oxid of zinc with bismuth, the 
lead and opium pill and the fluid ext. of coto bark. 
Irrigation of the rectum is also sometimes benefi- 
cial. Great care should be taken with the diet, which 
should consist of bland substances, such as milk and 
milk preparations, arrowroot, meat broths, etc. 



SPECIAL SYMPTOMS 147 

Cough 

Cough is often such a prominent symptom that 
the patient thinks if he can obtain relief from it his 
disease will be equally benefited, and he, therefore, 
insists upon some cough remedy. One should be 
very cautious, however, about yielding to the pa- 
tient's importunity unless there seems to be an im- 
perative indication for therapeutic interference. 
Under the open-air treatment the cough often takes 
care of itself, and, furthermore, the patient can be 
trained to suppress much unproductive coughing, 
for like other constantly recurring acts, coughing 
becomes ofttimes a habit and is yielded to upon 
slight provocation, when not necessary for the re- 
moval of secretion. 

In spite of the general treatment, however, and 
the endeavor to control it, the cough becomes so 
troublesome at times that some active interference 
is indicated. Treatment is necessary when (a) the 
cough is incessant, disturbing the rest of the patient 
and seriously dissipating his strength, for coughing 
is violent exercise; when (b) the cough is ineffec- 
tive, or hard, and it requires a continued paroxysm 
to expel the secretions ; and when ( c ) the secretions 
are, excessive and more or less continuous, cough- 
ing is necessary to get rid of them. Not infre- 
quently all three causes are operative. The object 
to be attained in treatment is to restrain the cough 
within the limits of effectiveness and lengthen the 
intervals. If the cough is hard and ineffective some 
expectorant is indicated, such as the chloride of 



148 PULMONARY TUBERCULOSIS 

ammonium or the aromatic spirits of ammonia, a 
teaspoonful of the latter in a glass of water and 
frequently sipped is most useful. With these, co- 
dein or heroin may be combined. The syrup of 
hydriodic acid is another remedy of value for this 
condition. Inhalations of thymol, eucalyptus, pine 
needle oil, tr. benzoin comp. and creosote are other 
means which may give relief. 

When the secretions are excessive, such remedies 
as terpin hydrate, eucalyptus oil, the compound tinc- 
ture of benzoin and creosote are indicated. Creo- 
sote can be employed by inhalation by means of a 
perforated zinc inhaler, the medicament being 
dropped upon a sponge placed in front of the in- 
haler and the following prescription can be used 
for this purpose : 

^ Menthol grs. v. (0.66) 

Alcohol ] 

Creosote j- aa Siiss ( 10.00) 

Chloroform J 
TT\, Sig. Put 5 to 10 drops on the inhaler and 
inhale the vapor for half an hour to an hour or 
more. 

If the upper air passages are irritable and dry, 
some of the soothing inhalations or sprays may be 
used, composed of alkaline solutions, or menthol, 
eucalyptus, camphor or carbolic acid in liquid al- 
bolene or petroleum. The following is a local ap- 
plication for the pharynx : 



SPECIAL SYMPTOMS 149 

^ Iodin grs. ii-v (0.1-0.3) 

Potass, iodidi grs. xvi-xlviii (1.0-3.0) 
Glycerini 3iiss (10.0) 

TTt Sig. Apply every day or every second day. 

When the cough is persistent and harassing, far 
in excess of the result produced — the elimination 
of secretions — and is interfering with nutrition 
and rest, one will often be obliged to employ some 
sedative agent, although simple remedies should 
first be tried, such as demulcent drinks, as sea-moss, 
or flax-seed tea, acacia, lacturarium, gelatine, or 
some form of lozenge. Of the opium sedatives, 
codein, heroin and dionin are the least objectionable 
and can be administered in capsules, tablets or in 
solution, either alone or in combination with chloro- 
form spirits or water, or aromatic spirits of 
ammonia. The doses are codein, grs. x /^ to Yz 
(0.01-0.03) ; heroin, grs. %4 to M2 (0.0025- 
0.005); dionin, grs. % to % (0.01-0.03). 

The following are some simple prescriptions con- 
taining the above : 

^ Heroin, grs. ii (0.13) 

Spts. ammon. aromat. 3v (20.0) 
Aquae ad §iv (120.0) 

TTt Sig. One teaspoonful in water three or 
four times a day. 



150 PULMONARY TUBERCULOSIS 

ty Dionin grs. v (0.2) 

Aq. amygd. amar. £iss (45.0) 

Aquae ad §iii (90.0) 

TTX Sig. One teaspoon ful three or four times 
a day. 

^ Codeinae, grs. viii-xvi (0.5-1.0) 

Syr. pruni virg. 

Aquae aa oii (60.0) 

T\\, Sig. One teaspoonful three or four times 
a day. 

fy Heroin grs. i-i>4 (0.06-0.09) 

Spts. chloroformi oii-3iii (8.0-12.0) 
Aquae menth. pip *iii (90.0) 

TTL Sig. Teaspoonful three or four times a day. 

" Not until all hope of recovery has vanished," 
wisely remarks Bonney, " should the comfort of 
the patient with distressing cough be promoted by 
the free exhibition of morphine, heroin or codeine." 

Fever 

As with the cough, the main reliance for combat- 
ting this symptom is out-of-door air and rest, — 
absolute rest, — as has been previously insisted upon. 
The patient may have to be kept at rest for weeks 
or months before the fever subsides, but so long as 
there is any hope of arresting the disease, the rest 
treatment must be maintained while the fever ex- 
ists. The sleeping porch is the best place for the 
fever patient, but if this is unattainable, a well- 



SPECIAL SYMPTOMS 151 

ventilated room with open windows is the next best 
arrangement; in the latter case the patient may be 
carried out to a couch or reclining chair upon a 
piazza for a portion of the day if it can be done 
without disquieting him. 

The employment of antipyretic drugs should, as 
a rule, be avoided, as they have but a transitory 
and deceptive effect; the only one I ever employ 
is pyramidon 5 to 6 grs. (0.3-0.4 gms.) either given 
in the form of tablets or in solution. In the latter 
case the requisite dose is dissolved in a glass of 
water and slowly sipped during an hour. Taken 
from three to six hours before the expected rise of 
temperature, a single dose is usually sufficient for 
twenty-four hours. I have sometimes found that 
a few doses of this drug will render the patient free 
from fever for a considerable time, and this fever- 
free interval will enable him to gain in weight and 
strength. Pyramidon can be used for a long time 
and according to Saugmun the cases of fever in 
tuberculosis which are not favorably influenced by 
it are few. It must always be remembered, how- 
ever, that the main reliance in the fever of tuber- 
culosis is fresh air and rest. 

Night Sweats 

Genuine night sweats are profuse and cover the 
patient with moisture so that his night garments 
are saturated. They must be distinguished from 
the comparatively slight perspiration common to 
any weakened condition which is often called 



152 PULMONARY TUBERCULOSIS 

" night sweats " by the patient. The real night 
sweats are usually a concomitant of the fever and 
are the result of toxic absorption. Like the fever, 
the main treatment is fresh air and rest. The bed 
clothing should be of light weight and only enough 
to render the patient comfortable. After the 
sweating has occurred the body should be rubbed 
dry and the night clothes changed. On retiring a 
glass of warm milk with one or two teaspoonfuls of 
brandy, as recommended by Brehmer, is often of 
aid, as is also bathing the body with cool water 
and vinegar or dilute acetic acid, which can also be 
done in the late afternoon. 

If the above general procedure does not avail, 
symptomatic drug treatment may temporarily be 
indicated and the two remedies I have found most 
efficient are agaracin gr. Mo and camphoric acid 
grs. 30, given in powder an hour or two before bed- 
time. Instead of the simple camphoric acid, one 
can use the pyramidon acid camphorate 12 to 15 
grs. (0.75-1.0) in powder or aqueous solution, 
and thus the one preparation is effective both for 
the fever and the night sweats 

Hemoptysis 

This is one of the most alarming symptoms to 
the patient and his friends, for it is often the first 
real evidence that tuberculosis may exist ; " the 
stoutest heart quails under it." As a matter of fact 
it is never fatal in the early cases and rarely so in 
more advanced ones. It may, however, much 



SPECIAL SYMPTOMS 153 

weaken and discourage the patient and may lead to 
the development of broncho-pneumonia, — a very 
serious complication. 

Most cases of hemorrhage would subside spon- 
taneously without medicinal treatment if the physi- 
cian and patient were content to trust nature; but 
almost invariably active treatment is demanded. If 
the hemorrhage is so slight as only to cause 
" streaked sputum," no treatment is indicated except 
to refrain from active exercise and keep in touch 
with the physician. When the hemorrhage is more 
than this and active treatment is indicated or ex- 
pected, the principle upon which one proceeds is that 
of lowering the blood pressure and thus favoring 
coagulation; hence one should, if possible, at the 
first ascertain the blood pressure. 

The practical plan of procedure, modified, of 
course, by individual conditions, may be sum- 
marized as follows : 

(a) Absolute rest in a well- ventilated room, in 
a semi-recumbent position. As Dr. James Jackson 
sixty years ago wisely said : " Rest of bidy and 
mind, and ' holding the tongue ' are quite as im- 
portant at the moment of bleeding as the medicinal 
articles." 

(b) An ice bag to the chest and cracked ice by 
the mouth. 

(c) Unless the blood pressure is abnormally low, 
the inhalations of the fumes of nitrite of amyl., 
using the glass pearls, or spirets containing three or 
five minims, or M.00 gr. nitroglycerine, either sub- 



i 5 4 PULMONARY TUBERCULOSIS 

cutaneously or upon the tongue; later, the nitrite 
treatment may be continued, if necessary, by sodium 
nitrite gr. I, every three or four hours for a day 
or two. 

(d) Purgation by the use of one ounce of mag- 
nesium sulphate, given twice, the first dose soon 
after the initial attack, and the second dose on the 
second day. 

(e) If the cough is annoying and frequent, small 
doses of codein or heroin, frequently repeated, % 
gr. of the former and V\2 to % gr. of the latter. 
One should be very cautious about giving morphin 
or continuing its use, although there may be occa- 
sions when one-eighth of a grain or even one- fourth 
may be indicated, given subcutaneously. The con- 
tinued use of the morphin is not without danger, 
for it may favor the development of broncho- 
pneumonia. 

The diet should be liquid and cold for the first 
day or two, such as milk with an alkali, soups, ice- 
cream, gelatine preparations, wine-jelly, etc. The 
patient*should be kept quiet in bed one week after 
all traces of blood have disappeared. 

Where the hemorrhage is severe and recurring, 
such as more frequently occurs in the latter stages 
of the disease, and the above means do not prove 
effective, there are other remedial measures which 
may be tried. Blood serum from the horse or rab- 
bit has been employed with success ; either fresh rab- 
bit's blood serum in 15 c.c. doses subcutaneously, 
repeated at intervals of four hours or longer, can 



SPECIAL SYMPTOMS 155 

be used, or the normal horse serum previously pre- 
pared, and now furnished in vials or syringes. In 
cases where the hemorrhage is recognized as com- 
ing from one lung and there is little active disease 
in the other, artificial pneumothorax, when it can 
be employed, has proved effective, but its use pre- 
supposes a pleural cavity free from adhesions or 
sufficiently so to allow adequate compression of the 
lung. 

Other remedies are atropine sulphate %o gf- sub- 
cutaneously, and pituitary substance or extract, said 
to be of especial value when the heart is very rapid 
and the respirations are increased. Chloride or 
lactate oftcalcium 10 to 20 grs. (0.6-1.2), or 
calcium sulphide 1 gr. (0.06) have been used with 
apparent success by some, but in my experience I 
have not found them of any great value. 

An old procedure is the application of ligatures 
to the extremities with a bandage of any kind, — 
a towel, sheet, or rubber tubing. First one thigh 
is constricted and then the other, and, if necessary, 
the arms in a similar manner. After half an hour 
or an hour, the bandages may be removed, one 
at a time. If the hemorrhage is so severe that the 
patient becomes exsanguinated, such remedies are 
indicated as in any case of great loss of blood, the 
infusion of physiological salt solution, and cardiac 
stimulants such as aromatic spirits of ammonia, 
champagne, oxygen, etc. When the blood fills the 
bronchi and upper air passages, coughing and deep 
breathing should be encouraged in order to get rid 
of the effused blood. 



156 PULMONARY TUBERCULOSIS 

Pain 

Pain in the chest, a frequent symptom, must be 
treated according to the cause if it can be deter- 
mined. If it is pleuritic, strapping the chest with 
adhesive plaster will generally give relief. When 
the cause is not evident, external applications, such 
as a belladonna or mustard plaster, tincture of 
iodine, heat or an appropriate liniment may be em- 
ployed. In other cases, aspirin or, exceptionally, 
a subcutaneous injection of codein or morphia may 
be required. Neuralgic or rheumatic pains and 
others of indefinite origin are to be treated by ex- 
ternal applications and internal medication as the 
indications require. 

Insomnia 

If the cough keeps the patient awake, this must 
be appropriately treated as indicated above, so also 
as regards night sweats. The best hypnotic is the 
open-air life and will generally suffice. It occasion- 
ally happens, however, that a patient cannot sleep 
well out of doors from nervousness or inability to 
keep warm, and under such circumstances it is bet- 
ter to sleep indoors; but the bedroom should be 
quiet, well-ventilated and darkened, or else one 
should cover the eyes with a dark bandage. A 
quiet, restful evening, and a glass of warm milk or 
a light meal at bedtime will conduce to a good 
night's sleep. Care should be taken that the feet 
are warm, for one cannot sleep with cold feet. If 
any drug is considered necessary, I have found 
trionol 5 to 10 grains the most satisfactory one. 



SPECIAL SYMPTOMS 157 

Dyspnoea 

This is not infrequently a distressing symptom 
in the advanced stages of the disease, and when 
there is extensive fibroid infiltration, thus greatly 
reducing the respiratory capacity. The main indi- 
cation is the restriction of the respiratory demands, 
within the smallest compass possible, by rest. 
Temporary relief may be obtained by some of the 
diffusible stimulants, such as ammonia, Hoffman's 
anodyne, and oxygen; strychnia and arsenic are 
also of value. When all else fails, opium in some 
form will be the last resort. 

Laryngeal Tuberculosis 

This complication is usually secondary to pul- 
monary tuberculosis and when advanced it is a very 
distressing and grave one. The diagnosis of 
laryngeal tuberculosis is not easy: hoarseness and 
pain in a tuberculous individual is strongly sugges- 
tive of it, but not proof, for other conditions may 
cause these symptoms, such as syphilis, and the dis- 
ease may be present while the symptoms are absent. 
The characteristic local signs of a well-marked case 
are more or less infiltration of the laryngeal tissues 
with loss of tissue and ulceration. 

The general treatment is that of the pulmonary 
disease, the open-air regime and rest of the larynx, 
— absolute interdiction of talking, whispering not 
even being allowed. Local treatment will depend 
upon the stage and character of the local condition ; 
in mild cases little or no topical treatment is indi- 



158 PULMONARY TUBERCULOSIS 

cated. When direct applications are to be made 
to the larynx, it will generally be wiser to call in 
the aid of one skilled in doing this and, hence, only 
such local treatment will be mentioned as the gen- 
eral practitioner can readily apply. 

In the first place, the larynx must be kept clean 
with some alkaline spray, such as Dobell's solution, 
to which rose-water may be added, one drachm to 
the ounce, which may be followed by a spray of 
argyrol ten to twenty per cent, solution. When 
there is pain and much discomfort, a spray of the 
following will give relief, the patient inhaling while 
it is applied: 

Menthol grs. v (0.3) 

Liquid petrolium %i (300) 

Til Sig. Use in vaporizer. 

I£ Menthol grs. iv (0.25) 

Olei eucalypti 

Olei gaultherise aa grs. xvi (1.0) 
Liquid petroleum 5iii, 3ii (100.) 

n\ Sig. Use in vaporizer. 

or simple liquid petroleum may be used. Medi- 
cated steam inhalations are also soothing. Lyon ' 
recommends the following: 

1 A Report of 241 Cases of Larygeal Tuberculosis treated at 
the Rutland State Sanatorium (Mass.) — Boston Medical and 
Surgical Journal, July 2, 1914. 



SPECIAL SYMPTOMS 159 

Tr. benzoin co. 3i (4.00) 
Eucalyptol 4 minims (0.25) 
Menthol 2 minims (0.12) 

ia 

When the epiglottis is involved and there is 
dysphagia, some local anaesthetic must be employed 
before eating, such as orthoform, anasthesin, a 
spray of two per cent, cocaine, or of heroin, three 
grains to the ounce. 

Much attention must be given to the feeding of 
the patient under these circumstances, else he will 
die of starvation. Small amounts of highly nutri- 
tious food, of a bland and semi-solid character must 
be given, such as eggs, raw, minced meat, junket, 
milk and milk preparations, minced chicken, thick 
soups, wine jelly, etc. Butter, olive oil and cream 
should be employed as much as possible in the prep- 
aration of the various articles of food. 

There are many other local applications and 
procedures which can be employed in the different 
stages of laryngeal tuberculosis, but these are best 
left to the skilled laryngologist. It is well to re- 
peat, however, that the basis of treatment of this 
condition is complete rest of the larynx and the 
rigid execution of the open-air treatment. 



CHAPTER X 

TUBERCULOSIS IN CHILDREN 

" In order to save a race that is threatened by an in- 
fectious disease, the best plan is to save the coccoon." 

Pasteur. 
" Tuberculosis of the adult is the end of the song 
begun at the cradle." 

Von Behring. 

There are certain peculiar difficulties in the diag- 
nosis of tuberculosis in children which do not exist 
in adults. In the first place, active tuberculous 
disease of the lungs is infrequent, and, second, 
tuberculous bronchial glands are much more fre- 
quent; therefore, in making an early diagnosis, 
we have to make it chiefly from the symptoms — 
the detection of the diseased bronchial glands — 
and by the tuberculin test. If it is true, as is now 
generally held, that the majority of consumptives 
are infected when young, the importance of detect- 
ing the disease in childhood is at once apparent, 
for then is the golden opportunity of so regulating 
the child's life that the latent tuberculosis may never 
become active. 

Symptoms 

What are the suspicious symptoms? 

In general, they are those indicating a definite 
160 



TUBERCULOSIS IN CHILDREN 161 

depression of health, such as loss of weight or 
failure to gain in weight, anaemia, malnutrition, loss 
of appetite, lassitude, irritability, and sometimes a 
dry, hard cough and night sweats. There may be 
also an irregular rise of temperature. It is true 
that all or many of these symptoms may occur 
from other causes and are not characteristic of 
tuberculosis ; but they should always make one 
suspicious and prompt a thorough examination and 
continued observation. It is also true that tuber- 
culosis may exist and yet there may be no evidence 
of serious disturbance of health or no marked con- 
stitutional symptoms, but in this case no treatment 
is required other than good hygiene, for the de- 
fensive resistance of the body is equal to the attack 
of the tuberculous infection. This is especially true 
in later childhood. If there is a family history of 
tuberculosis, or an active case in the child's family, 
this fact should make one all the more suspicious. 

Physical Signs 

The physical signs are also not characteristic. 
On inspection the child may show evidence of 
anaemia and malnutrition. On percussion there is 
nothing definite ; there may be slight dullness on one 
side or the other of the sternum at the level of the 
second intercostal space in front and in the inter- 
scapular region behind. Auscultation is no more 
satisfactory. We have the D'Espine sign, often 
difficult to make out, of questionable value, and only 
to be obtained when the bronchial glands are of 



1 62 PULMONARY TUBERCULOSIS 

considerable size. It consists in the persistence of 
the bronchial whisper or bronchophony heard over 
the vertebrae below the level of the seventh cervical 
spine. When positive, it merely indicates the en- 
largement of the tracheo-bronchial glands, but tells 
us nothing as to the cause or nature of the enlarge- 
ment. Another sign, when it can be determined, 
is diminished respiration over one lobe, especially 
the right lower lobe. 

When all is said, however, percussion and auscul- 
tation give but little definite information unless 
there is lung infiltration or consolidation. 

The X-Ray 

The X-ray is of especial value in determining 
the presence of bronchial glands, but the Ront- 
genographs must be carefully made and interpreted 
by one experienced in X-ray work. When the 
glands are present, the plate shows spots of shading 
along the right side of the vertebral column, and 
also along the hilus. Here, again, it must be borne 
in mind that although the bronchial glands may be 
shown to be enlarged, the X-ray does not tell us 
whether they are actively tuberculous or not. 

The Tuberculin Test 

The von Pirquet cutaneous test is of the most 
value in diagnosis in children under five years of 
age. Of course, a positive reaction only indicates 
a tuberculous infection, but tells us nothing as to 
its activity. It is of greater significance when nega- 



TUBERCULOSIS IN CHILDREN 163 

tive than when positive; but with other suggestive 
symptoms and signs a positive von Pirquet adds 
to the weight of evidence in favor of active glan- 
dular tuberculosis. With older children, the sub- 
cutaneous tuberculin test may be used, the dose, of 
course, being proportionately smaller than with 
adults; for example, with children of eight or ten 
years of age, 0.001 to 0.01 mg's of Koch's old 
tuberculin may be employed. 

The conditions under which this test should be 
made are the same as with an adult. The patient 
should be afebrile ; the reaction phenomena are also 
the same. Used with care and in proper doses, the 
subcutaneous tuberculin test is quite safe. Holt 
declares that he has seen no unfavorable symptoms 
from this form of the test even in the youngest 
infants. 

The Diagnosis 

In order, then, to make a definite or probable 
diagnosis of active bronchial gland tuberculosis, we 
must have enough or all of the following evidence : 

(a) Constitutional symptoms, such as weakness, 
undue fatigue, malnutrition, anaemia, fever, rapid 
pulse and a dry cough without any discoverable 
physical signs of disease. 

(b) A positive von Pirquet or subcutaneous 
tuberculin test. 

(c) A positive D'Espine sign. 

(d) X-ray evidence of enlarged bronchial glands. 



164 PULMONARY TUBERCULOSIS 

Treatment 

When we have established the diagnosis, the child 
is to be placed under treatment, which is, in general, 
that of the open-air regime. The diet should be 
abundant and rich in fats and proteids. The child 
should sleep under open-air conditions. There 
should be rest periods during the day and over- 
fatigue should be avoided. If there is no fever or 
other acute symptoms requiring complete rest, the 
child may for a part of the day attend an open-air 
school, where rest periods and lunches are afforded. 
Drugs are not generally indicated except for especial 
symptoms; if, for example, anaemia is present, iron 
or arsenic is indicated, such as the syrup of the 
iodide of iron or Fowler's solution. Tuberculin 
has been employed with varying opinions as to its 
value by those who have used it. Sunshine is im- 
portant, and the child should be encouraged to rest 
and play in the sunshine. 

Pulmonary Tuberculosis 

When the child shows evident physical signs of 
pulmonary involvement, the diagnosis depends upon 
the interpretation of these signs, together with the 
evidence obtained from the symptoms, and when 
sputum can be obtained, upon the result of its ex- 
amination. We may have signs of a bronchitis or 
a consolidation which may or may not be of a tuber- 
culous origin. If the child has been exposed to 
the infection in the family; if a chronic cough de- 
velops; or fever not evidently caused by other con- 



TUBERCULOSIS IN CHILDREN 165 

ditions; if consolidation is present and persists, 
particularly if it involves the middle lobe of the 
right lung anteriorly (Holt) the case is probably 
one of tuberculosis. 

Slight or more marked physical signs must be 
interpreted very much as in the case of an adult, 
and be considered in connection with the symptoms. 
One does not so frequently hear rales in children 
as in adults, and the same physical signs in children 
are not always so significant of tuberculosis as with 
adults. 

Treatment 

The treatment of children with active pulmonary 
tuberculosis is practically the same as that for 
adults. If possible, the child should be sent to a 
sanatorium where the treatment, as a rule, can be 
more efficiently carried out. Outdoor sleeping, 
rest, nutritious food and sunshine are the essentials. 
It is of the greatest importance that the young child 
should be protected from all sources of infection, 
whether from the milk or a tuberculous individual 
in the home, and, likewise, its strength should be 
carefully conserved during the convalescence from 
measles and whooping cough, which diseases render 
the child peculiarly susceptible to the tuberculous 
infection. Later in childhood, when resistance to 
tuberculous infection or the extension of an already 
existing infection, is not well established, the child 
should be given such general care, in regard to fresh 
air, food, rest, bathing, etc., as will secure and main- 
tain a high standard of health. 



CHAPTER XI 

CLIMATE IN THE TREATMENT OF TUBER- 
CULOSIS 

" The glorious sun, 

Stays in his course and plays the alchemist; 
Turning, with splendor of his precious eye, 
The meagre cloddy earth to glittering gold." 

King John, Act III, Sc. I. 

" Soon as a man finds himself spitting and hacking on 
rising in the morning, he should immediately take pos- 
session of a cow and go high up into the mountains and 
live on the fruit of that cow." 

Celsus. 

Before considering the uses of climate in the 
treatment of pulmonary tuberculosis, it will be well 
to get a clear idea of what we mean when we speak 
of climate. The climate of any locality is its aver- 
age weather conditions, and by weather we mean 
all those atmospheric elements which are noticed 
by sight, feeling, or observed by instruments; and 
these include the temperature, humidity, wind, the 
condition of the sky as to cloudiness or sunshine, 
and the occurrence of precipitation as rain or snow. 
By the term weather, we mean these conditions as 
observed at a particular time or during a short 
period, while by climate, we mean the aggregate of 
166 



CLIMATE IN THE TREATMENT 167 

weather conditions extending over a longer period. 
The average value of these conditions of any region 
constitutes its climate ; for example, we say that the 
winter climate of northern New England is cold with 
a considerable precipitation in the form of snow, and 
much cloudiness, but the weather of a single winter 
may be comparatively mild with little snow and 
much sunshine. 

In estimating the climate of any region one must 
know the average range of the various climatic 
elements : (a) the average or normal temperature, 
its daily range, and the extremes of heat and cold; 
(b) the humidity, estimated as the average relative 
humidity; (c) the precipitation in inches; (d) the 
wind, its velocity and prevailing direction; (e) the 
number of clear, fair, and cloudy days. The lati- 
tude and longitude of the locality should also be 
known. Such data for a large number of resorts 
are now available from government weather 
bureaus; the climatic chart of New York will serve 
as an illustration. (Fig. 22.) 

Since such favorable results have been obtained 
in any and all climates in the treatment of tuber- 
culosis by the skillful application of the open-air 
regime, the role of climate does not now occupy 
the paramount place it once did. Formerly a 
change to a more favorable climate was considered 
the most essential factor in the treatment, and when 
once the patient had reached the climatic El Dorado, 
he was left to himself to follow his ordinary or an 
extraordinary mode of life with but little, if any, 



z 




o 




H 


J »A 


< 




> 






uajniAV 


CO 




« 




o 




fa 


•uuinjnv 


o 




Q 




O 


•jauimng 


s 




w 




fa 






•3nudg 


o 








•* 


•jsqmaAO^i 


w* 




p 






'J9qai9;d9g 



°2 



to 2; 

« w 

D W 

o H 

•* « 

W*S 



•qaJBH 



Sr s 



rH 50 06 M 

2 « d i-: -*' 



«> -H I- U3 O 



O l-l «o >o OJ 



H : s is I 8 

So Jo ° ° to *" 

168 



c c 
.2 "" 

rt 60 



K fa 



c>- <0 ^ 

i * w 

o i> > 

S " c« 



ao o> 
•* oo 



■5 fa < 



bo" 

||| 

E E | 
3 s 2 

C C B 

<U jj aj 

w S? Sf S? 

S 2 « 2 

•S 1/ 4) U 

rt > > > 

8 < < < 



CLIMATE IN THE TREATMENT 169 

medical oversight. A few recovered and more died 
under this go-as-you-please plan. 

Experience has demonstrated, however, that the 
open-air treatment can be successfully carried out 
anywhere, even in the crowded city; for more de- 
pends upon the method, the careful attention to de- 
tails, the skilled medical supervision, and the com- 
plete fulfillment of the out-door life than upon any 
especial climate. Nevertheless, it is obvious that, 
with an efficient hygienic-dietetic method, favorable 
climatic conditions are an added advantage. The 
purer the air the more favorable the other climatic 
conditions, the more perfectly the open-air treat- 
ment can be effected. Other things being equal, 
we therefore desire to send the consumptive patient 
to that locality where he will obtain the pure air and 
as many as possible of the other climatic excellen- 
cies, with the purpose of more perfectly following 
out the out-door life. 

The Favorable Climate 

The essential favorable climatic conditions for 
pulmonary tuberculosis are: (a) pure air free from 
bacterial impurities, and dust; (b) the maximum 
amount of sunshine — good weather; (c) absence 
of or protection from high winds; (d) moderate 
dryness and more or less equability; (e) a medium 
or cool average temperature. 

Altitude, as in mountain climates, has been re- 
garded as an element of much value in its influence 
upon tuberculosis, and most excellent results have 



170 PULMONARY TUBERCULOSIS 

been obtained in the high altitudes, such as at the 
Colorado and New Mexico resorts. The advantage 
of altitude is in the greater purity of the air, the 
greater number of clear and bright days, the intense 
insolation under low atmospheric temperatures, and 
the general stimulating effect upon metabolism. 
Whether or not the lessened barometric pressure ex- 
ercises any specific influence is doubtful ; it increases 
the respiratory and cardiac function, which in cer- 
tain cases may be of value. 

Good weather, bright sunny days, is an obviously 
desirable climatic condition, for it affords a better 
opportunity for the out-door life and under more 
comfortable and cheerful conditions. 

As to temperature, experience has shown that the 
tuberculous individual makes greater gain in a 
medium or cool temperature, in the winter than in 
the summer. 

Dryness of the air is considered another im- 
portant factor on account of its anti-catarrhal effect. 
With a dry climate, however, we have less equabil- 
ity of temperature, and the lower the relative 
humidity, the greater the daily range of temper- 
ature; thus, for example, the climate of Egypt is 
a very dry one, but the difference between the day 
and night temperature is from 20 to 30 degrees. 
Equability, however, except in the case of elderly 
or feeble persons, is not an important factor. 
Wind is only harmful when the patient is directly 
exposed to it. On the other hand, when he is pro- 
tected from it, its influence is beneficial in purifying 
the air. 



CLIMATE IN THE TREATMENT 171 

Dr. Knopf thus briefly and admirably gives the 
characteristics of a favorable climate. He says : 
" The ideal climate for the average pulmonary 
patient, in the earlier and more hopeful stages of 
the disease, is the one where extremes of temper- 
ature are not great, with the purest atmosphere, 
relatively little humidity, much sunshine, and all 
conditions which permit the patient to live com- 
fortably out-of-doors the largest number of days 
out of the year, and the largest number of hours 
out of the twenty-four." 

Beneficial Effects of a Favorable Climate 

In the first place, a favorable climate, such as has 
been indicated above, permits one to pursue the 
open-air life more completely and comfortably than 
in an unfavorable one. Second: It exercises a 
favorable influence upon tissue change, producing 
increased metabolism, improved nutrition, and a 
general stimulation of the vital processes. Third: 
It often favorably influences the mental attitude. 
One is more cheerful and hopeful in continuous 
pleasant weather, and under sunny skies. Out-door 
life is more attractive when every day is a pleasant 
one; if one is able to take exercise, he can do so 
with greater ease and with a larger choice of out- 
door amusements. Again, complications, such as 
bronchitis, laryngitis, pneumonia, pleurisy, etc., are 
less likely to occur in a favorable climate than in 
such weather conditions as usually obtain, for ex- 
ample, in the northeastern portion of this country, 
not far from the Atlantic coast. 



172 PULMONARY TUBERCULOSIS 

As to the influence of a change of climate upon 
the local condition, experience has shown that it is 
often greatly benefited; there is a diminution of 
the cough and a lessening of the expectoration. In 
brief, although a change of climate does not exer- 
cise any specific effect, yet, if rightly selected, it 
may be expected to improve the general condition, 
as to appetite, nutrition, etc., and diminish local 
activity. 

However valuable a factor a favorable climate 
may be, it must always be borne in mind that it is 
only a part of the general treatment and that not 
the most important one. Of first importance is 
proper hygiene, diet, and discipline, and skilled 
medical supervision. Without these the most fav- 
orable climatic conditions will prove elusive. 

When is a Change of Climate Desirable 

A change of climate may be desirable for many 
reasons: the prominent one is that it may increase 
the patient's chance of recovery. He may not be 
doing well where he is, and the climate of his pres- 
ent locality may be a particularly unfavorable one. 
The environment of the patient may be such, as to 
family, or social conditions, that a change is ad- 
visable. The temperament of the patient may be 
such that change of scene and new surroundings 
will conduce to a more favorable mental attitude. 
Proper control of the patient may not be possible 
where he is. Age, sex and complicating diseases 
are other reasons which may render desirable a 



CLIMATE IN THE TREATMENT 173 

change. The financial condition of the patient is, 
of course, a determining factor in making any 
change, unless one goes to a state or charitable sana- 
torium. It is better to make the best of home con- 
ditions than to go to a more favorable climate and 
suffer deprivations. 

When a change of climate is under consideration, 
the first point to be decided is whether the general 
and local condition is such that any change will be 
beneficial; and, second, the particular climate and 
resort most favorable for the individual case. 
Furthermore, one must determine whether the pa- 
tient should go to an " open " resort in the selected 
climate or enter a sanatorium there. 

Having decided upon the climatic resort, some 
knowledge of the local conditions should be ob- 
tained, such as its sanitation, facilities for comfort- 
able living, and the presence of a reliable physician 
to whom the patient can be referred. Opportun- 
ities for amusements and religious observances are 
an important consideration for some patients. 

Cases Suitable for a Change of Climate 

The class of cases most suitable for, and most 
likely to be benefited by, a change of climate are: 

(a) Early cases with slight local involvement 
and little or no constitutional disturbance. 

(b) Further advanced cases in the quiescent state 
with no serious constitutional disturbance. These 
two classes of cases do well in the elevated regions, 
as in Colorado or New Mexico. 



174 PULMONARY TUBERCULOSIS 

(c) Advanced cases with little general dis- 
turbance, and a moderate degree of resistance. A 
dry, moderately warm climate in regions of little 
or no elevation, such as southern California or the 
pine belt of the South, is most suitable for such 
cases. 

(d) Cases of cavities, if not extensive and in 
which the disease is quiescent may be sent to the 
altitudes or the low-land regions. 

(e) Cases more or less advanced in which soften- 
ing and excavation are going on, accompanied with 
much cough and expectoration, and with more or 
less constitutional disturbance, if they can be com- 
fortably transported, they may have their life pro- 
longed and live more comfortably in a moderately 
warm, dry region, such as southern California or 
the southern pine belt ; indeed, a quiescent condition 
of the disease may be established. 

With regard to tuberculosis complicated with 
other diseases, such as kidney, liver or cardiac dis- 
eases, or diabetes, each patient must be individually 
considered. A climate that is favorable for the 
tuberculosis may be unsuitable for the complicating 
disease. 

In contemplating a change of climate for any 
case of pulmonary tuberculosis, we have to consider, 
on the one hand, the physical condition of the 
patient, both constitutional and local, and his 
economic and social circumstances; and, on the 
other hand, the climatic characteristics of the pro- 
posed resort, its general topography, its social en- 



CLIMATE IN THE TREATMENT 175 

vironment, and the opportunity of obtaining com- 
petent medical supervision. Only thus can one 
expect to obtain successful results from a change 
of climate. 

Not all cases are suitable to be sent away at all, 
and this is always the first question to be settled 
when a change is under discussion. Rarely should 
a patient be sent far away who is suffering from 
acute symptoms, such as fever, etc. ; nor should far- 
advanced, hopeless cases, as many have done and 
died far away from home. Others of little per- 
sistence and self-control, and who cannot be de- 
pended upon to carry out the plan of treatment, if 
sent away at all should go to a sanatorium where 
they can be under discipline. 

Favorable Climates for Pulmonary Tuberculosis 

The climates which have been found by experi- 
ence to be favorable for tuberculosis in its curable 
stage are: (a) the high altitudes, as Denver, 
Colorado Springs and Estes Park in Colorado, all 
about 6000 feet high; Silver City (5800 feet), Al- 
buquerque (5000 feet), and Fort Bayard (4450 
feet) in New Mexico. 

(b) The medium altitudes, as Saranac Lake in 
the Adirondack Mountains (1600 feet); Liberty, 
N. Y. (2300 feet); Asheville, N. C. (2250 feet), 
in nearly all of which resorts there are good sana- 
toria. Many other eligible climatic regions can 
also be found in the White Mountains, the Berk- 
shires, Massachusetts, Vermont, Pennsylvania and 



176 PULMONARY TUBERCULOSIS 

northern New York. In the southwestern and 
Rocky Mountain region of the United States there 
are many resorts of medium altitude, such as Las 
Cruces, New Mexico (3800 feet) ; Phoenix, Ari- 
zona (1100 feet); and Tucson (2400 feet). In 
southern California, sixty or more miles inland, 
there are various places with a mild, dry, sunny 
climate, such as Redlands (1350 feet), Riverside 
(800 feet) and the Ojai Valley (900 to 1200 feet). 

(c) Of the sea-level resorts, there are many 
places in the dry southern pine belt with a mild 
sunny winter climate, such as Aiken, S. C. ; Sum- 
merville, S. C. ; Augusta, Ga., and others in North 
and South Carolina, Georgia and the interior of 
Florida. On the coast of southern California, there 
are San Diego, Los Angeles, Santa Barbara, Pasa- 
dena, and others with an eligible climate, both win- 
ter and summer. 

The climatic resorts that have been mentioned are 
but a few of the many in different parts of the coun- 
try which offer favorable conditions for pulmonary 
tuberculosis and which fulfill the essential climatic 
conditions, viz. : pure air free from dust, sunshine, 
protection from high winds, an average cool tem- 
perature, and moderate dryness. 

In regard to the high altitudes, there are certain 
contraindications which should be mentioned; they 
are: (1) advanced age; (2) too great involve- 
ment or softening in both lungs; (3) cases compli- 
cated with kidney or heart disease, diabetes, asthma, 
or emphysema; (4) extensive fibroid infiltration 



CLIMATE IN THE TREATMENT 177 

with dyspnoea; (5) cases in which there is great 
irritability of the nervous system; (6) advanced 
tuberculous laryngitis. 

Dettweiler thus well sums up the advantages and 
limitations of climate in the treatment of tuber- 
culosis : " A specific or truly immune climate does 
not exist. The value of a climate depends upon 
how perfectly it can aid in the production of im- 
proved nutrition and the restoration of all functions 
to a normal physiological standard, working 
through the body and mind to accomplish this. 
Tuberculosis can be cured in every climate where 
extremes do not exist. The individual condition of 
the patient alone determines the choice. To accom- 
plish a cure the plan of treatment and the method 
of life the patient follows hold the first con- 
sideration." 



CHAPTER XII 

PROPHYLAXIS 

" Prevention is better than cure, and far cheaper." 

John Locke. 

There are three main lines of effort in the pre- 
vention of tuberculosis: First, the protection of 
the infant and child from a tuberculous infection 
whether from within (in the home) or without. 
Second, the prevention of infection in the adult 
from one suffering from active tuberculosis. 
Third, the prevention of an active tuberculosis from 
a latent tuberculous focus, either in the child or 
adult. 

The Infection of the Child 

It is generally conceded that tuberculous infec- 
tion occurs in childhood, and the occurrence of the 
positive von Pirquet reaction, almost without ex- 
ception, in children over five years of age would 
appear to prove this. How do these children be- 
come infected? Either through association with 
some one in the household who is suffering from 
open tuberculosis, as mother, father, brother, sister, 
nurse or an intimate friend; or through infection 
brought in from the outside by means of the cloth- 
ing, shoes, pet animals, etc., or through contamina- 
178 



PROPHYLAXIS 179 

tion of the nursery floor or wherever the child 
creeps or plays. In a certain number of cases gland 
and bone tuberculosis is caused by the bovine tuber- 
cle bacillus in milk. 

The Protection of the Child 

There may be a known case of open tuberculosis 
in the home or it may be undiscovered; conse- 
quently, any suspicious symptoms, such as cough, 
loss of strength, debility, etc., occurring in the 
mother, nurse or attendant, or any other member 
of the family, should at once be investigated. No 
nurse or attendant should be allowed to take charge 
of an infant or young child without a previous ex- 
amination of the lungs. If the mother has open 
tuberculosis, the isolation of the child is the only 
safe course. When this is impossible, the infant 
should not be nursed by its mother, and she should 
take every precaution to avoid infecting her child. 
She should not fondle or kiss it, and should always 
hold something before her mouth when coughing, 
and avoid coughing in the vicinity of the child. 
If the father or any other member of the family 
has tuberculosis, it is easier to keep them out of the 
way of the child. 

If the mother is known to have had tuberculosis 
before the birth of her child, the child is, as we 
know, not born tuberculous, but may inherit a 
special susceptibility to the disease; hence, especial 
attention should be given to increasing its resist- 
ance by general good hygiene. Care in feeding, 



180 PULMONARY TUBERCULOSIS 

open-air exposure, cool sponging, etc. Particular 
care should be taken to protect the child from the 
exanthematous diseases, whooping cough, diph- 
theria and tonsilitis, and if it contracts any of them, 
the convalescence should be carefully guarded. In 
artificial feeding, the milk should either be obtained 
from tuberculin tested cows or be pasteurized, and 
this is done by heating the milk in an Arnold's pas- 
teurizer or a home-made one of similar construc- 
tion, to 145 ° F. for at least twenty minutes and 
then cooling it rapidly. As the child grows older, 
all hygienic measures should be taken to strengthen 
it, as has been indicated in Chapter X. When a 
case of tuberculosis exists in the family, every child 
should at once receive a careful examination. 

Prophylactic Measures in the Case of an Adult 
Suffering from Pulmonary Tuberculosis 

In the case of an adult tuberculous person at 
home, the physician must see to it that he has care- 
ful and detailed instructions as to the safe disposal 
of his sputum and the safeguarding of the family, 
and subsequently watch must be kept to see that the 
instructions are rigorously carried out. In the 
house the ordinary paper sputum receptacle is con- 
venient, which can be burned with its contents; 
abroad, pieces of gauze or Japanese paper, folded 
several times, can be used and then put in an im- 
pervious paper bag, which is subsequently burned. 
Such an arrangement is less conspicuous than a 
pocket spit cup. The use of the common handker- 



PROPHYLAXIS 181 

chief is obviously dangerous. In coughing, one 
should not do so in the presence of others, and 
should hold a piece of cloth or paper handkerchief 
before his mouth. The mouth should be cleaned 
frequently, at least before meals, with some alkaline 
solution, and the teeth brushed before and after 
meals. The hands should also be washed before 
eating. 

A beard or mustache is not desirable, for it may 
collect particles of sputum. The patient should not 
handle articles used by children or others, or leave 
articles about which may be handled. If all the 
dishes used at the table are washed in boiling water, 
it does not seem to me necessary for the patient to 
have his own separate set, as is often recommended, 
and to do so makes an unpleasant distinction. It 
is to be borne in mind, as Baldwin truly says, that 
" the careful, cleanly consumptive has a right to 
associate with other people in the ordinary pursuits 
of business and pleasure." On the other hand, ev- 
ery consumptive has an obligation to "protect his 
fellow human beings so far as possible from the 
disease." The patient should sleep by himself, and, 
if possible, in a separate room. 

A " clean " consumptive is commonly said to be 
a " safe " one, and this is measurably true, as sana- 
torium experience has shown; but man is fallible, 
and with the best intentions and care a slip may 
occur in some way or other. Therefore, in a fam- 
ily where there are children, if there is a case of 
tuberculosis, the safest plan is to remove the con- 
sumptive to a sanatorium or elsewhere. 



1 82 PULMONARY TUBERCULOSIS 

Tuberculosis in the Workshop 

In the workshop or factory, or wherever many- 
persons are brought together in close contact, it 
occasionally happens that there is present a case of 
active tuberculosis, and yet the individual is able 
or feels compelled to work. This, however, hap- 
pens less frequently at the present time on account 
of the medical supervision and welfare work now 
carried on in many of the large industrial establish- 
ments, and the provision made for the consumptive 
workman when he is discovered. When it does 
occur, the consumptive workman should be in- 
structed in the ordinary precautions to be taken in 
coughing and expectorating. 

The Prevention of Active Tuberculosis from a 
Latent Infection 

As almost every one has some tuberculous infec- 
tion, the problem is to prevent this inactive infection 
from becoming active, and the sum and substance 
of doing this is the avoidance of a continued ex- 
posure to the tubercle bacillus from an uncleanly 
consumptive; for it must always be remembered 
that the immediate environment of a careless con- 
sumptive is the most common and greatest source 
of danger, and, secondly, being well and without 
symptoms, to keep so, by healthful living and work- 
ing under healthful conditions. Regularity in one's 
habits, temperance, the avoidance of excesses, 
proper and regular meals, sufficient rest, exercise in 
the open, open-air sleeping, good ventilation in 



PROPHYLAXIS 183 

workshop, office and the home, the avoidance of 
over- fatigue, are the means every one should em- 
ploy to live happily, healthfully, and to avoid active 
tuberculosis. 

Dusty Occupations 

As is well known, the mortality from pulmonary 
tuberculosis is high in the dusty trades, such as 
steel grinding, the use of emery wheels, stone cut- 
ting, pottery, cotton, tobacco and shoe manufacture. 
To prevent the inhalation of the irritating dust, ap- 
pliances should be provided for the removal of the 
dust, such as hoods connected with fans or respir- 
ators should be worn. The laws of many states 
now require some provision for removing the dust 
in the various grinding processes, and thus shield- 
ing the workman from the injurious influence of 
the metallic or mineral particles. 

Disinfection 

When a room or apartment has been occupied by 
a consumptive, it is the physician's duty to see that 
it has been thoroughly cleaned and renovated before 
occupancy again. Fumigation does some good, but 
a thorough cleaning and renovating of paper and 
paint, and exposure to sunlight and daylight is far 
more effective. Everything that has been used by 
the patient should be subjected to steam disinfection 
or destroyed. . 



184 PULMONARY TUBERCULOSIS 

The Physician's Duty in the Prevention of 
Tuberculosis 

The physician from his intimate relation with 
so many households has an exceptional opportunity, 
and hence a definite obligation to disseminate 
knowledge with regard to the prevention of tuber- 
culosis in the community where he practices his pro- 
fession. He can impress upon the consumptive 
who is under his care the vital importance of pre- 
venting the spread of his disease to those about him 
through a proper and safe disposal of the sputum. 
He can seek by every means in his power to make 
an early diagnosis and institute timely treatment. 
He can see that the public of his particular com- 
munity is informed of the causes of the disease, 
and the part each person can do in protecting him- 
self and others from the infection; and that it 
understands the way in which infection takes place 
and how it may " become inoperative and powerless 
for harm." To do this is both the privilege and 
obligation of the physician, for at the present day 
the conscientious physician must regard the pre- 
vention of disease as one of his sacred duties. 



CHAPTER XIII 

AFTERCARE AND MARRIAGE 

" Keep what you have." 

Plautus. 

" Oh yet we trust that somehow good 
Will be the final goal of ill, 
To pangs of nature, sins of will, 
Defects of doubt and taints of blood." 

In Memoriam. Tennyson. 

Aftercare 

It is now generally conceded that sanatorium 
treatment, and, indeed, the open-air treatment any- 
where for a limited period, does little more in the 
majority of cases than train the patient in the open- 
air regime and start him on the road to recovery. 
After that he must himself make the journey back 
to assured health if he is to arrive there. If he 
deviates from the known way, relapse is likely to 
follow, which experience has shown has been only 
too frequent. The patient may be so far toward a 
permanent arrest that he can resume a part or the 
whole of his former occupation, or undertake some 
kind of work ; but he should do this only under the 
advice of his physician under whose observation he 
should remain, and by whom he should be period- 
ically examined. 

185 



186 PULMONARY TUBERCULOSIS 

Generally, from the force of circumstances, the 
" improved " or " arrested " case will have to return 
to his former occupation, which is probably the best 
plan, unless the occupation and the environment are 
manifestly unhealthy; for the mental and physical 
strain in a familiar occupation is far less than in 
learning a new one, and the income greater. 

From his experience during treatment, the patient 
will have recognized the extreme importance of 
hygienic living and fresh air ; and, therefore, he will 
seek to embrace every opportunity for obtaining 
fresh air day and night, and continue to model his 
life upon the plan pursued while taking the cure. 
The following letter of a former patient, quoted by 
Dr. Bardswell, 1 well indicates the kind of life a 
cured consumptive should follow. He says : 
" With regard to aftercare, I only carry on treat- 
ment in so far as the discipline and training of the 
sanatorium has made it second nature with me to 
observe certain laws. For instance, I make my- 
self eat enough. In the old days I ate when I 
wished, and not much at that. I never fail to look 
out for fresh clean air. I sleep in a breeze winter 
and summer. I look on a draught as an angel from 
heaven. I choose open-air recreations rather than 
the theater, etc., and always keep myself busy. By 
so doing I have no time to think of tuberculosis, 
but at the same time I never forget that I may still 
have got the damned thing in me." 

If the disease is only in the process of arrest and 

1 " The Practioner," January, 1913, London. 



AFTERCARE AND MARRIAGE 187 

yet the general condition is satisfactory, the patient 
can, not infrequently, do part of a day's work, and 
be out-of-doors the rest of the day. For example, 
I have a patient in this condition who spends his 
forenoons at his business and plays golf in the after- 
noons, and thus successfully follows the " cure " 
and at the same time continues his business. All 
excesses should be avoided, whether mental or 
physical ; the weight, appetite and strength watched, 
and every retrogression from the normal standard 
of health must be immediately investigated. A 
bronchitis, influenza, or any respiratory disease 
should receive immediate and careful attention. 

The cardinal rules of living which the cured con- 
sumptive must ever bear in mind are rest, sufficient 
and regular nourishment, fresh air and the avoid- 
ance of excesses and over-exertion. Furthermore, 
both the physician and patient must not forget 
Osier's aphorism that " Benefit is usually a matter 
of months, complete arrest a matter of years." 

Marriage and Tuberculosis 

This is a question upon which the physician is not 
infrequently called to give his opinion, although it 
is not always followed, the patient deciding the mat- 
ter from his own inclination without much regard 
for the future. 

In the first place, should a woman who has ob- 
tained an arrest of the disease marry and bear 
children? In answering this question, one should 
consider it from the standpoint of danger to the 



188 PULMONARY TUBERCULOSIS 

woman, and also that of the offspring. Will the 
latter be predisposed to tuberculosis? If the arrest 
of the disease has been maintained for two years or 
more and the general health is satisfactory, and the 
conditions of life when married will not entail 
serious demands upon the strength, marriage can 
be allowed and probably there will be no recurrence 
of the disease. There should, however, be a suf- 
ficiently long interval between the child-bearing 
periods to permit the mother to fully recover her 
strength. As to the child, there is no reason why 
it should not be strong and healthy if carefully 
reared. 

If the prospective husband is an arrested case and 
the woman is healthy, there is no reason why they 
should not marry, or why the children should not 
be healthy. If, however, the husband will be ob- 
liged to support his family by his own efforts, it 
is possible that the burden may be too heavy and 
cause a recurrence of the disease. 

If the disease on the side of the man is not ar- 
rested but quiescent, and the general condition is 
good, while the woman is well, even then marriage 
may be acquiesced in, if the woman knows the facts 
and is willing to take the chances of infection, and 
the man the extra burdens of married life; and, 
again, the offspring may be healthy and remain so 
if protected from the source of infection. 

When a husband is actively tuberculous but the 
disease is not far advanced and the wife is strong 
and healthy, it seems to me that it is a question 



AFTERCARE AND MARRIAGE 189 

for them alone to decide whether they should have 
children, and as in the former case, the child may 
be healthy and remain so if removed from the 
father and placed under good hygienic conditions. 
As a general proposition, no actively tuberculous 
woman should marry and bear children, for the 
result is generally disastrous. There are cases, 
however, in which this has happened, and not only 
has a healthy child been born, but neither during 
the pregnancy nor after it has the disease become 
more acute with the mother; but these are excep- 
tional cases. Again, the mental effect upon a 
young woman who is tuberculous and wants to 
marry but feels she cannot do so, may have a worse 
influence upon the disease than marriage or even 
pregnancy. One can also readily imagine cases 
where the tuberculous wife would be ready to take 
the grave risk of pregnancy for the sake of an off- 
spring. If a woman after her marriage should be 
found to be tuberculous, she should be advised to 
avoid conception. 

Pregnancy and Tuberculosis 

When an actively tuberculous woman becomes 
pregnant, there have been varying opinions given 
as to what should be done ; and different procedures 
have been advised for different stages of the preg- 
nancy and different stages of the disease. No in- 
terference with pregnancy should be undertaken 
without the clearest indication that the condition of 
the wife will be benefited thereby, and the decision 



190 PULMONARY TUBERCULOSIS 

of the physician must be based solely upon the prob- 
able effect upon the wife. The interruption of 
pregnancy to prevent the birth of a predisposed 
child is never justified. It is also to be remembered 
that the interruption of a pregnancy is a great shock 
to the system and may be far more injurious than 
to allow the pregnancy to be completed, and unless 
there is a fair prospect that the life of the mother 
can be saved or considerably prolonged, an induced 
abortion should not be done. 

Although it is true that pregnancy in an actively 
tuberculous woman has generally been followed, 
after the birth of the child, by an exacerbation of 
the disease, such is not always the case, for oc- 
casionally pregnancy has produced marked and last- 
ing improvement. On the other hand, the arti- 
ficial termination of the pregnancy has been fol- 
lowed by an increased activity of the disease. 

The confinement of the tuberculous woman 
should be quickly terminated under anaesthesia, and, 
of course, lactation should be avoided. Every 
effort should be made to support and strengthen the 
mother during the puerperium. 

From what has been said, it will be seen that the 
existence of pregnancy in a tuberculous wife is not 
always or of necessity prejudicial to the course of 
the disease ; nor is the fact that the pregnant woman 
is tuberculous a justification in itself for the termi- 
nation of the pregnancy. Each case should receive 
the most careful individual consideration, and only 
when one is convinced that the case is doomed if 



AFTERCARE AND MARRIAGE 191 

the pregnancy goes on, should it be interrupted. 
Advise as we will with regard to the marriage of 
a tuberculous woman, if our advice is contrary to 
her inclination, it will often be disregarded. 



CHAPTER XIV 

CASES 

" Examples draw when precept fails, 
And sermons are less read than tales." 

Prior. 

I. G. B. Male, setat 45. Accountant. 

Mother died of tuberculosis at the age of 57. 
Generally well. Upon three different occasions 
within the last four months he raised a small 
amount of blood. He now has some cough with 
expectoration in the morning. No loss of weight 
or strength and no dyspnoea. Good appetite. His 
voice is somewhat husky. He is a healthy looking 
man weighing 155% lbs. 

Physical examination: T. 99.8 . P. 74. R. 24. 

Questionable dullness at both apices and possibly 
some roughening of respiration. Examination of 
sputum, positive. 

In this case a diagnosis could not have been made 
from the slight and doubtful physical signs, but the 
hemorrhage made it practically certain even if the 
sputum had not been positive. The cough and ex- 
pectoration added to the certainty of the diagnosis. 

The prognosis is good, for the general condition 
is excellent and there is no constitutional disturb- 
192 



CASES 193 

ance. The " open-air " treatment for a while with 
later graduated exercise will probably produce an 
arrest of the disease. 

II. E. A. Female, setat 21. Cook. 

Father died of acute tuberculosis. Never very- 
well up to 17 years of age; after that stronger. 
Her present complaint is a tired feeling and head- 
aches. Says she feels flushed in the afternoon. At 
first said she had no cough, but on questioning she 
thought she might have a little in the morning but 
no expectoration. She had lost considerable weight 
and strength, and had some shortness of breath on 
exertion. The appetite was " pretty good " and she 
was working. Her general appearance was fair. 

Physical examination : T. 100. P. 124. R. 28. 

Slight dullness at the left apex with a rough in- 
spiratory sound. Some moist rales in the left 
base. 

The diagnosis of tuberculosis in this case depends 
largely upon the symptoms, — the increased tem- 
perature and pulse, the slight cough, the loss of 
weight and strength and dyspnoea upon exertion. 
The disease is evidently active and the patient needs 
rigorous sanatorium treatment. 

The prognosis can only be determined by the re- 
sponse to treatment. At present a guarded progno- 
sis should be given, for the history is poor and the 
symptoms are out of proportion to the slight phy- 
sical signs. 

III., D. F. Female, aetat 22. Shopgirl. 

Family history negative. Generally well. For 



194 PULMONARY TUBERCULOSIS 

the last six months she has had a " tired feeling " 
and been " nervous." She coughs occasionally, but 
has no expectoration. She has lost weight and 
strength, and has some dyspnoea. Amenorrhcea 
for four months. Appetite poor. In appearance, 
she is of medium height, thin and weak. 

Physical examination: T. 99. 5 . P. 92. R. 
28. 

Nothing abnormal found in the lungs. 

The above well illustrates the class of cases called 
" suspicious " in which no definite diagnosis can be 
made. The loss of weight and strength, dyspnoea, 
and poor appetite make one strongly suspect that 
tuberculosis exists. Such cases should be kept under 
observation and treated on general " open-air " 
principles. 

IV. I. F. Female, setat 25. 

Tuberculosis nurse. Mother died at iy years of 
age from tuberculosis. Five years ago she had 
typhoid fever. Has been feeling particularly well. 
A week before the consultation she had a slight 
hemorrhage and subsequently streaked sputum. 
She says she has no cough, but some expectoration 
which, on examination, was negative. No loss of 
weight or strength, or no dyspnoea. Appetite " very 
good." Thinks she has been having a little after- 
noon temperature. Is working. She weighs 
2I 5 l A lbs. and looks well. 

Physical examination: T. 100.5 P. 78. R. 
18. 

Questionable dullness in the left supraclavicular 



CASES 195 

space with somewhat rough respiration. Other- 
wise, negative. 

From the slight physical signs, a diagnosis could 
not be made ; but the hemorrhage and increased tem- 
perature make the diagnosis of active tuberculosis 
practically certain. 

The prognosis is favorable if active treatment is 
at once instituted. The comparatively low pulse is 
a favorable omen. 

V. S. G. Male, setat 29. Salesman. 

Family history negative; no known exposure to 
the disease; always well though never very strong. 
Subject to " head colds." Chief complaint is " get- 
ting tired." He has lost about five pounds in weight ; 
no loss of strength and no dyspnoea. Slight cough 
and expectoration. Appetite excellent. He feels 
able to work. In appearance he looks well and 
weighs 171-% lbs. 

Physical examination: T. 99. 2 . P. 76. R. 
16. Lung capacity, 250 cubic inches. 

There is slight but definite dullness at the right 
apex and on deep inspiration a few fine persisting 
rales, both above and below the clavicle. 

Here the definite physical signs indicate a prob- 
able slight tuberculous infiltration; but the absence 
of any marked symptoms shows that there is no 
toxaemia. 

The prognosis is very good, and the patient need 
not necessarily be removed from his work, but kept 
under observation and placed under good hygienic 
conditions. 



196 PULMONARY TUBERCULOSIS 

VI. T. G. Male, aetat 21. Student. 

Mother died of tuberculosis, and sister has been 
in the sanatorium with the same disease. He was 
at home during his mother's illness. Has always 
been well. Has had a " cold " with intermissions 
for two months. The night before consulting his 
physician, he had a small hemorrhage. He has a 
slight cough with streaked sputum. No loss of 
weight or strength or no dyspnoea. Appetite pretty 
good. Is attending to his duties. His appearance 
is that of health, although somewhat thin. 

Physical examination: T. 99 . P. 72. R. 24. 

Slight and doubtful dullness at both apices, with 
possibly somewhat roughened respiration and pro- 
longed expiration. Examination of sputum, posi- 
tive. 

Here is a case in which the first definite symptom 
was the hemorrhage which was the cause of con- 
sulting his physician. Without the positive sputum 
or the hemorrhage a definite diagnosis could not 
have been made. 

A favorable prognosis was given and sanatorium 
advised. Four years and a half later he died. On 
account of the family history, a guarded prognosis 
should have been given. 

VII. J. H. Male, aetat 47. Dentist. 

Family history negative. No known exposure. 
Always fairly well. Has had more or less hoarse- 
ness and cough for some time. Twenty-five and 
again four years ago he had a hemorrhage. He 
now has a cough with expectoration, which is posi- 



CASES 197 

tive. He has lost ten pounds in weight, although 
his present weight is 178 lbs. His strength is fair 
and he does a full day's work. Some dyspnoea. 
The appetite is good. His appearance is that of 
health. 

Physical examination: T. 99 . P. 76. R. 16. 

Marked dullness over both fronts, with broncho- 
vesicular respiration, especially at the right apex. 
The voice is H — h and there is a moderate number 
of rales. The same condition exists in the cor- 
responding areas behind. There is hoarseness 
which is suggestive of tuberculous laryngitis. 
Five months later the rales had disappeared, ex- 
cept above the left clavicle; he had gained 11 lbs., 
his strength had improved; the temperature range 
was from 97.4 to 98 . He had been sleeping and 
living in an open tent in the country, going to his 
business every day. 

The above represents a case of advanced tuber- 
culosis of slight activity with little if any toxaemia, 
and where the resistance not only maintained itself 
but gained upon the disease, and this in spite of 
strenuous daily work. Although such cases rarely 
become permanently arrested, they remain quiescent 
for long periods, and the individual not only has 
the appearance of health, but is able to follow his 
occupation. When once, however, the resistance 
is broken by some intercurrent disease, such as an 
influenza or a sharp hemorrhage, for example, acute 
symptoms often quickly supervene and a fatal re- 
sult follows. 



198 PULMONARY TUBERCULOSIS 

VIII. D. R. Male aetat 22. Leather busi- 
ness. 

Father died of pulmonary and laryngeal tuber- 
culosis, and he was more or less intimately asso- 
ciated with him. Generally well. A well de- 
veloped, muscular man, with a deep, full chest. Has 
been working in dusty places. He has had a cough 
for three or four months, with some expectoration, 
which was negative. Once he thought he had 
streaked sputum. No loss of weight and strength, 
and no dyspnoea. Good appetite; weight, 141 lbs. 

Physical examination: Slight increase of pitch 
with somewhat roughened and possibly diminished 
respiration at the left apex; otherwise, negative. 
Subsequently, seven months later, the examination 
was negative and he had gained 11^ lbs. The 
Roentgen examination at this time showed no evi- 
dence of " acute infiltration of lung tissue," but 
" very definite peribronchial thickening together 
with an increase in the bronchial gland shadow," 
" the markings of the right root and particularly of 
the ascending division were abnormally promi- 
nent." 

In the opinion of the Roentgenologist, the plates 
were consistent with a diagnosis of early pulmonary 
tuberculosis. In this case a definite diagnosis could 
not be made, either from the symptoms, physical 
signs or X-ray findings. The weight of all the 
evidence, however, — the intimate association with 
his father, the continuing cough, the streaked 
sputum, the slight physical signs, and the X-ray 



CASES 199 

picture, — all pointed toward an early tuberculous 
infection. 

The question to be decided was the future plan 
of life : Here was a young man well started in his 
business career. Should he abandon it for an out- 
door life, or continue in it under observation? 
Under all the circumstances, it was decided that the 
only safe course was to give up his business and 
in-door life in the city and live an out-door life in 
the country. This was accordingly done, and he 
went West upon a ranch. 

IX. J. B. Male, setat 28. Fireman. 

Family history and exposure, negative. He com- 
plained of a dry cough for the past two weeks and 
soreness across the chest; chilly sensations; poor 
appetite. 

Physical examination: T. 98.2 °. Weight, 
132^ lbs. 

Dry rales throughout the chest with suspicious 
signs at the left apex. 

The diagnosis then made was chronic bronchitis 
with a question of infiltration at the left top. 
Twelve days later the examination showed many 
constant fine moist rales throughout the upper left 
lobe, and the X-ray plate verified the suspicion of 
infiltration at the left apex. 

This case shows how a general bronchitis may 
conceal an underlying tuberculous lesion, and em- 
phasizes the importance of repeated examinations 
and continued observation of all cases of bronchi- 
tis. 



200 PULMONARY TUBERCULOSIS 

X. J. C. Male, aetat 39. Inside work as 
stockkeeper. 

He is one of eleven children, of whom four have 
died of tuberculosis. He has always been well, al- 
though he is now about sixteen pounds under 
weight. His chief complaint is soreness in various 
joints, weakness, night sweats and pain in the left 
side, which, he says, " catches his wind." 

Physical examination: T. 101 . P. 115. 

Dullness in the left scapular region. Two days 
later, there was marked dullness, or flatness, over 
the lower left lobe with distant bronchial respira- 
tion, and at the apex of the same lung, slight dull- 
ness with broncho-vesicular respiration and a few 
moist rales. The diagnosis was made of pleurisy 
with effusion, and incipient tuberculosis. The case 
was reported and sanatorium treatment advised. 

This case illustrates the importance of a careful 
examination of the apex of the lung when there is 
an effusion in the lower half. The family history 
would also make one suspicious of tuberculosis. 

XI. J. T. Male, aetat 31. Machinist. 

A healthy looking, well nourished man, weighing 
185 lbs. Family history and exposure to infec- 
tion, negative. Eight months ago some one sug- 
gested to him that he might have tuberculosis, and 
he presented himself for examination at a tuber- 
culosis dispensary. From the result of the exami- 
nation, he was sent to a sanatorium. Three months 
later he was examined at another dispensary and 
no evidence of tuberculosis was discovered. He 



CASES 201 

now says that he has a slight cough in the morning 
with a little expectoration, and thinks he has lost 
some strength; no dyspnoea; appetite good. While 
at the sanatorium he was put to work. 

Physical examination: T. 98.6 . P. 88. R. 
24. 

Sputum negative. Examination of the lungs 
negative. 

Here is a case in which there was either a slight 
infection, which was promptly arrested under sana- 
torium treatment, or in which there was a mistaken^ 
diagnosis. In such doubtful cases, either one of 
two courses may be followed: the patient may be 
kept under observation, or, if the symptoms and 
physical signs are suspicious and all pointing in one 
direction, active treatment may be instituted; the 
latter is the safer course. 

XII. S. T. Female, aetat 24. Married. Frail 
in appearance. 

Her husband has pulmonary and laryngeal tuber- 
culosis. Has had a cough for four or five months, 
with expectoration which was negative. She has 
lost weight and strength and has some dyspnoea. 
She says she has twice had some hemoptysis, but 
the record does not state how much. Appetite poor. 
Two months ago she was examined at a dispensary 
and told she had no tuberculosis. 

Physical examination: T. 98.6 . P. 88. R. 
32. 

Nothing found in the lungs. 

The diagnosis of tuberculosis was made, founded 



202 PULMONARY TUBERCULOSIS 

wholly upon the symptoms and the exposure to in- 
fection through association with her husband. It 
is possible, of course, that the diagnosis was wrong, 
but with such an array of symptoms, viz., loss of 
weight and strength, shortness of breath, poor ap- 
petite, and a history of hemoptysis, together with 
the exposure to infection, the diagnosis seems fully 
justified. She was advised to take active " open- 
air " treatment. 

XIII. F. S. Male, setat 19. Electrical en- 
gineer. 

A healthy appearing, well nourished young man 
weighing 162 lbs. 

Family history negative ; exposure, been asso- 
ciated in his work with a man who had a cough 
with expectoration. Generally well, athletic. 
Within the last week he has had hemoptysis on 
three different occasions, a cupful in all, he thinks. 
He has a slight tickling in his throat and slight ex- 
pectoration of mucus; no other symptoms. 

Physical examination: T. ioo°. P. 64. R. 
14. 

Lungs negative; expansion, 6 cm. 

The diagnosis of tuberculosis was made and san- 
atorium treatment advised; but he felt so well he 
did not think it was necessary to give up his work. 

The diagnosis in this case was made almost solely 
upon the fact of the hemoptysis, there being no con- 
stitutional symptoms and no physical signs. The 
increased temperature was probably only tempo- 
rary from the result of the hemorrhage. The ex- 



CASES 203 

posure to infection also strengthened the diagnosis. 

XIV. J. K. Female, aetat 22. Housewife. 

Of medium height and rather thin; weighs 126 
lbs. ■ 

Family history negative. Exposure : a " chum " 
of hers, she says, with whom she has constant as- 
sociation, has tuberculosis. Always well. Is now 
four months pregnant. Four months ago she was 
in the hospital for ten days with acute bronchitis, 
she says. For the past three months she has had 
pain in the chest. Three weeks ago she was ex- 
amined at a tuberculosis dispensary and was told 
she must go to a sanatorium. She has no cough, 
but sometimes a little expectoration, which was 
negative. There is loss of flesh and strength, and 
dyspnoea. The appetite is not very good. 

Physical examination: T. 99.8 . P. 96. R. 24. 

At the left base from below the angle of the 
scapula, there were fine and medium moist rales in 
abundance. Otherwise, the lungs were negative. 
Day camp or sanatorium advised. 

This case is of interest for two reasons : First, 
is the condition at the left base a tuberculous one? 
" Abnormal physical signs at the base," says Brown, 
" should be looked on as nontuberculous until def- 
initely proved so." Considering the exposure to 
tuberculosis and the symptoms, one is inclined to 
consider this a case of tuberculosis until proved the 
contrary. Second, especial attention should be 
given to all symptoms pointing to tuberculosis in a 
pregnant woman. When in doubt, active treat- 



304 PULMONARY TUBERCULOSIS 

ment should be established so that the woman may 
be in the best possible condition at the birth of her 
child, for experience has shown that after confine- 
ment any existing tuberculous lesion is likely to be- 
come more active. 

XV. D. H. Male, aetat 26. Bookkeeper. 

Family history : brother died of tuberculosis, and 
he was living with him at the time. Never has been 
ill since a child. Two years ago had a hemorrhage 
of a moderate amount, and a repetition of the same 
two months ago. Says he has had no other symp- 
toms except a cold for about a week. Has a slight 
tickling cough with a very little expectoration. No 
loss of weight or strength and no dyspnoea. Ap- 
petite very good. Is able to work. 

Physical examination: T. 99. 2 . P. 96. R. 
16. 

Sputum, positive. Marked dullness over both 
fronts down to about the fourth rib. Respiration 
very rough. Voice +. A few rales at both apices. 
On the back in the corresponding area the same 
signs are found but the rales are more numerous, 
extending down to the middle of the scapula. 

Diagnosis: advanced pulmonary tuberculosis. 
The striking characteristic of the case is the extent 
of the pulmonary lesion in comparison with the 
almost complete absence of constitutional symp- 
toms. The man does not feel ill and is able to 
work. It is very doubtful if so extensive disease 
can ever be arrested, and so long as the equilibrium 
is maintained between the resistance and the disease, 



CASES ; 205 

the man is comparatively safe and may live in- 
definitely. 

As to treatment, it is probably the wisest course 
to attempt an arrest by the open-air cure. On the 
other hand, he may do as well to continue his oc- 
cupation under good hygienic conditions of work 
and living, watching carefully for any break in the 
resistance. 

XVI. O. P. Male, setat 42. Dealer in furs. 

Family history and exposure to infection, nega- 
tive so far as known. Has worked hard since six- 
teen years of age and always been well. Six 
months ago he had a fracture of the ankle and has 
not felt well since. Three months ago he began to 
lose weight and strength, and had a cough and 
chills, and thinks he had some fever. He consulted 
a laryngologist who, from the appearance of the 
larynx, referred him for examination of the lungs. 
At that time there was a degree rise of temperature 
in the afternoon, a pulse of 84 and weight of 146 
pounds. He had a troublesome cough with a small 
amount of expectoration which was positive. He 
had no appetite and had dyspnoea on exertion. He 
was taking some exercise and attending to busi- 
ness. 

Physical examination: Marked dullness at both 
apices with broncho-vesicular respiration, voice + 
and a few fine, moist rales on deep inspiration. 

Diagnosis: Moderately advanced, active tuber- 
culosis. 

Treatment : He was put at rest in a well-venti- 



206 PULMONARY TUBERCULOSIS 

lated room in his cottage by the sea-shore. At the 
end of two months the temperature was normal and 
there was but slight cough and expectoration. The 
weight was increasing, and there was general im- 
provement in the constitutional condition. Two 
months later there were but a few sticky rales upon 
the physical examination. A year after the first 
examination, he had practically no cough, no tuber- 
cle bacilli in the sputum, and said he had not felt 
so well for years; weight, 156 lbs. Meantime he 
had made a trip to Europe. The physical examina- 
tion was that of an arrested case. He has been per- 
fectly well for the last six and a half years and 
all the time has been attending to his business. 

This case illustrates the quick response of the 
resistance to the infection under only a moderate 
degree of the rest and open-air treatment, and the 
permanence of the cure. Not every case will re- 
spond so rapidly and so perfectly. 



INDEX 



Actinomycosis, 93 

Advance of tuberculosis, mode of, 92 

After care, 185-187 

Age incidence of tuberculosis, 50 

Air, tidal, 16 

complemental, 16 

supplemental, 16 

residual, 16 
Alcohol in etiology of tuberculosis, 60 
Altitude, high, indications for, 173, 174 

contra-indications, 176 
Anaemia, 142 

in children, 164 
Anesthesin in laryngeal tuberculosis, 159 
Anatomical period, 24 
Anorexia, 141 

treatment of, 141 
Aphorisms of L. Brown, 82-84 
Aretaeus Cappadox, 22 
Arsenic, 143 
Asthma, 97 

Atropin in hemoptysis, 155 
Auenbrugger, 26 
Auenbrugger's dictum, 67 
Auscultation, outlines of, 68-71 

method of, 73-75-76 

B 

Bacilli tubercle, 34, 35 
bovine, 36 
channels of entry of, 40 

207 



208 INDEX 

Bacilli tubercle — continued 

diagnostic value of, 39, 81 

effects of gastric juice on, 35 

effects of, on tissues, 40 

how destroyed, 35 

in healed lesions, 41 

morphology of, 34 

staining of, 36 

antiforrain method of, 36, 37 
Ellerman and Erlander method of, 38 
Ziehl-Nielsen method of, 36 

vitality of, 34 
Bath, cold, 120 

dangers in, 121 

how to take, 121 
Baillie, Matthew (1793), 26 
Bayle (1774-1816), 26 
Blood serum in hemoptysis, 154 
Bovine bacilli in children from milk, 26 
Bowditch, Dr. H. I., advice in " Young Stethoscopist," 

75,82 
Breathing, bronchial, 69-77, 9 1 

broncho-vesicular, 69-76 

cog-wheeled, 77 

exercises in health, 21 

rough, 76 

vesicular, 68-75 
Bronchiectasis, 95 
Bronchitis, 96 
Bronchi, 11 



Calcium in hemoptysis, 155 
Capacity, vital of lungs, 16-18 

average lung for height, 19 
Caseation, 40 
Cardiac, Lesions, 98 

displacement, 92 
Cavities, 44, 91 
Celsus, 22 



INDEX 209 

Chest, bony framework of, 1 

alar, 13 

circumference of, 16 

emphysematous, 12 

flat, 13 

funnel-shaped, 13 

increase expansion of, 15 

local changes in, 13 

measurements of, 17 

modifications of by disease, 12 

movements in respiration, 14 

pigeon breasted, 13 

rachitic, 13 

unilaterial changes in, 13 
Children, tuberculosis in, 160 

physical signs in, 161 

symptoms of tuberculosis in, 160 

diagnosis of bronchial gland tuberculosis in, 163 

pulmonary tuberculosis in, 164 

tuberculin test in, 162, 163 

X-ray in diagnosis, 162 
Classification of tuberculosis, 88-90 
Climate, definition of, 166 

beneficial results of, 171 

cases suitable for change of, 173 

elements of, 167 

factors to be considered in change of, 174 

favorable, 169, 171, 175 

former estimate of, 167 
Climates favorable for pulmonary tuberculosis, 175-177 
Clothing, 119, 126 
Cog-wheel breathing, yy 
Complications, 102 
Conheim (1877), 29 
Constipation, treatment of, 116, 144 
Cough, 147 

diagnostic significance of, 63 

in early tuberculosis, 61 

prevention of rest by, 112 

training to suppress, 147 

treatment of, 147-150 



210 INDEX 

Cough — continued 

useless, 147 
Creosote, inhalation in cough, 148 



Day's plan, 123 
D'Espine Sign, 161 
Dettweiler, on climate, 177 
Diaphragm, action of in respiration, 4 

diminished movement of in tuberculosis, 
Diaphragmatic respiration, 4, 5 
Diagnosis, early, 52, 88 

differential, 93-98 

of advanced tuberculosis, 90, 92 
Diarrhoea, cause of, 146 

diet in, 146 

treatment of, 146 
Dietetic treatment, 115 

in constipation, 116 

in diarrhoea, 146 
Diet in hemoptysis, 154 

needs for special, 115, 116 

in advanced cases, 131 

suggestive articles of, 117 
Debility in tuberculosis, 141 
Diseases predisposing to tuberculosis, 59 
Disinfection, 183 
Dust, 57 

tubercle bacilli in, 34 
Dyspnoea, 132, 157 

in advanced cases, 157 

treatment of, 132, 157 

E 

Emphysema, 9 

Examination of patient, scheme of, 56 

of upper respiratory tract, 64 

physical, 62 

position of patient in, 63 



INDEX 211 



Exercise, 117 

dangerous forms, 119 

varieties, 118 

when harmful, 118, 119 

when permissible, 118 
Expectoration, safe disposal of, 180 
Expiration, movements of chest in, 14 

mechanism of, 14 
Eugenics and tuberculosis, Davenport, 47 



Fat, an increase of in the diet, 115 
Fever, diagnostic significance of, 53, 54 

absolute rest in, 125, 150 

in tuberculin reaction, 87 

out-door air in, 150 

prognostic significance of, 102 

pyramidon in, 151 
Fibrosis, 41, 44 
Fibroid phthisis, 44 
Fistula-in-ano, 55, 102 
Focal reaction, 87 
Food, in the treatment of tuberculosis, 115, 117 

ingestion and digestion of, as a factor in prognosis, 106 

milk, 115 

proteins, carbohydrates, fats in, 115 

suggestive articles of, 117 
Fremitus, tactile, 79 



vocal, 70, 78 
Friction sounds, 71 



Galen (130 a. d.), 24 
Galloping consumption, 49 
Gastro-intestinal disturbances, 144 
Gee, sayings of, 44, 78 
Giant cells, 40 
Glands, bronchial, 10 

bronchial, tuberculosis of in children, 160 



212 INDEX 

H 

Habits, an etiological factor in tuberculosis, 59, 60 
Healing, true, 44 
Hemoptysis, causes of, 44, 45 

artificial pneumothorax for, 137, 155 

blood pressure in, 153 

dangers from, 152 

diagnostic significance of, 54 

diet in, 154 

excessive, cause of, 45 

external applications in, 153, 155 

from cardiac lesion, 54 

medicinal treatment of, 153-155 
Hippocrates (460 b. c), 22 
History, family, 57 

past, 58 

of present illness, 60 
Hygiene, personal, 122, 123 



Infection, mixed, 43 

ancient belief in, 29 

and period of incubation, 29 

exposure to, 58 

primary, 160 

without symptoms, 62 
Influenza, 95 
Inspection of chest, 63 
Insomnia, 156 

treatment of, 156 
Intercostal spaces, 2 

artery, 2 

muscles, 2 
Inspiration, muscles engaged in, 14 

in ordinary, 14 

relation to expiration, 15 
lacerates, 23 



INDEX 213 

K 



Klencke (1843), 28 
Knopf, on Climate, 171 
Koch, Robert, 32, 33 



Laennec (1781), 27 
Larynx, tuberculosis of, 157 

diagnosis of, 157 

treatment of, general, 157 
local, 157, 159 
Lazarus Riverius (1638), 29 
Louis (1827), 27 
Lungs, 8 

boundaries of, 9 

elasticity of, 9 

examination of base, 80 

landmarks of, 12 

lobes of, 9, 10 

lymphatics of, 10 

physiological difference in right apex, yy 

shape of, 9 

weight of, 8 
Lungs, malignant disease of, 94 

average vital capacity for height, 19 

vital capacity of, 16, 17, 18 

M 

Malaria, 95 

Marriage of the tuberculous, 187 

effect upon tuberculous woman, 189 

if husband is tuberculous, 188 

when safe after arrest, 188 
Maxims and random hints, 129, 130 
Milk, preparation of, 116 

pasteurization of, 35, 180 
Mixed infection, 43 
Morphin in hemoptysis, 154 



2i 4 INDEX 

Morton Richard (1689), 25 
Mountain climates, 169, 175, 176 
Muscles of respiration, 14 
Musical ear, value of, 73, 74 



N 



Neurasthenia, 96 
Niemeyer (1866), 28 
Night sweats, 151, 152 

cause of, 152 

false, 151 

treatment of, 152 
Nitrites in hemoptysis, 153 
Nurse, children's, examination of, 179 



O 



Occupation, in diagnosis, 57 

dusty, 57, 183 
Open-air school, 164 
Orthoform in irritation of pharynx, 146 

in laryngeal tuberculosis, 159 
Osier, his summing up, 123 
Out-door life, 113 

arrangements for, 113 

contra-indications, 113 

occupation in, 114 

results attained by, 115 

sleeping, 113 



Pain in chest, 156 

treatment of, 156 
Pathology of tuberculous inflammation, 40, 41 
Percussion, outlines of, 66-68 

in early tuberculosis, 73 

technic of, 72 
Pleura, function of, 5 

adhesions of, 5, 138 



INDEX 215 

Pleura — continued 

costal layer of, 8 

lymphatics of, 7 

parietal layer of, 6 
Pleural cavity, 6 

inferior cul-de-sac, of, 7 
Pleurisy, 97 

pain in, 156 
Pneumonia tuberculous, 49 
Pneumothorax, artificial, 137, 140 

duration of treatment, 140 

gas embolism in, 138 

indications, 137, 138 

danger in, 140 

for hemoptysis, 137, 140 

importance of X-ray in, 138 

in far-advanced cases, 138 

local anesthesia in, 139 

method of induction, 138 

pleural adhesions in, 138 
Post-mortem appearances of tuberculous lung, 42 
Phthisis, types of, Bayle, 27 

dualistic theory of, 27 

unity theory of, 27 
Predisposition, acquired, 46 

inherited, 46 
Predisposing diseases of respiratory tract, 59 
influenza, 59 
measles, 59 

recurring bronchitis, 59 
typhoid fever, 59 
whooping cough, 59 
Pregnancy and tuberculosis, 189 

effect upon tuberculous woman, 189 

effect upon the offspring, 188 

interruption of, 189 

treatment of, 190 
Prevention of active disease from latent infection, 182 
Prognosis, 99 

age and sex and, 105, 106 

character and intelligence of patient and, 105 



216 INDEX 

Prognosis — continued 

complications and, 102, 103 

constitutional symptoms and, 103 

factors in, 100 

family predisposition and, 104 

fever and, 102 

food and, 106 

fistula-in-ano and, 102 

general propositions, 101 

importance of, 99 

in acute lobar and broncho-pneumonic tuberculosis, 
49, 50 

in arrested disease, 186, 187 

pregnancy and, 102 

previous life and habits and, 103 

pulse in, 102 

temperament and, 104 
Prophylaxis, 178 

in adults, 180 

in children, 178, 179 

duties of physician in, 184 
Psychology of tuberculous, 121, 122 
Pulse, 64 

fever and, 102 



Rales, 70, 71, 79, 80 

infrequency in children, 165 

in incipient tuberculosis, 80 

localized importance of, 80 

sonorous, Dr. Bowditch on, 80 

varieties of, 70 
Reaction, tuberculin, 87 

cutaneous, 86 

dangers of, 87 

diagnostic value of, 88 

focal, 87 

local, 87 
Relapses, 185 

dangers of, 187 



INDEX 217 

Resistance, age of greatest, 34 

age of least, 51 

in prognosis, 106 
Resorts, open, in 
Respiration, physiology of, 14 

abnormalities of, 19, 20 

in incipient tuberculosis, 64 

muscles engaged in, 14 
Respiration, bronchial, 69, 77 
Respiratory exercises, 21 
Respiratory murmur, slight modifications of, 81 

distinctions of, in Gee, 78 
Respiratory tract, upper, examination of, 64 
Rest, 112, 125 

in febrile cases, 112 

afebrile cases, 112 

indications for, 112 

technic of, 112, 114 
Results of treatment, scheme, 107, 108 
Ribs, movements of in respiration, 2 

counting, 3 



Sanatorium treatment, in 

indications for and against, 11 1 
Sanatorium, selection of, 111 

for children, 165 

medical supervision of, 11 1 
Sex in prognosis, 105 
Sleep, out-of-doors, 113, 114, 126 

prevention of by cough, 112, 147 
Smoking, 60 

Schedule for day's plan, 130-13 1 
Scheme for recording physical signs, 71-72 
Spirometer, use of, 16 
Sputum, examination of, 36, 37 

disposal of, 122, 180 

examination by antiformin, 38 

by Ellerman and Erlander method, 138 

streaked, 153 



218 INDEX 

Stages of pulmonary tuberculosis, 88, 89, 90 

Stethoscope, 74 

Strength, loss of, as symptoms, 61 

" Suggestions and Aids," 124, 129 

Symptoms, suspicious, 53, 54 

importance of in early diagnosis, 55, 61, 62 
Sylvius (1670-1672), 24 
Syphilis and tuberculosis, 59 
Syphilis, pulmonary, 94 



Teeth, care of, 117 
Temperature in children, 161 

influence on by rest, 112 

in tuberculin test, 87 

significance of, in early tuberculosis, 65 

when to take, 65 
Thorax, 1 

deformities of, 12, 13 
Thoracic, cavity, 5 

lining of, 5 
Tobacco, 60 
Toxaemia, 42, 48, 112 
Trachea, 11 
Treatment, 109 

climatic, 166-177 

music in, 122 

tuberculin, 134-137 
Treatment of acute miliary tuberculosis, 48 

cases requiring no treatment, 109 

dietetic, 115, 117, 131, 144 

especial methods of, 133 

in open resort, 11 1 

in sanatorium, 11 1 

of advanced cases, 131, 132 

of arrested cases, 186 

of children, 164, 165 

of complications, 152 
Tubercle bacilli, 34 

effects of cold on, 35 



INDEX 219 



Tubercle bacilli — continued 
of desiccation on, 35 
of germicides on, 16 
of heat on, 35 
of light on, 35 
in sputum, 35 
Tubercles, history of, 40 

calcification of, 41 

caseation of, 41 

fibrosis of, 41 
Tuberculin in diagnosis, 86, 87, 88 

action of, 134 

in children, 162 

preparation of, 134 
Tuberculin reaction, 

cutaneous, 86 

diagnostic value of, 88 

dosage, 136 

focal, 87 

local, 87 

results from, 136 

signs of, 87 

suitable cases for, 135 

technique of administration, 135 

treatment, theory of action, 134, 137 
Tuberculosis, acute miliary, 42, 47 
Tuberculosis, acute lobar pneumonic, 42, 49 
Tuberculosis, acute broncho-pneumonic, 49, 50 

advanced, 90, 91, 92 

fibrous-caseous, 51 

in workshops, 182 

modes of advance, 92, 93 

old laws regarding, 30 

post-mortem appearances in, 42 

stages of, 88, 89, 90 



Villemin (1865), 28 
Virchow (1850), 27 
Voice, auscultation of, 78 



220 INDEX 

Vomiting after cough, 145 

treatment of, 145 
von Pirquet test, 85, 86 

W 

Wassermann test, 95 

Weight in early tuberculosis, 64 

loss of as a diagnostic symptom, 53, 54 
Whispered voice, 70, 78 



X-ray in diagnosis, 85 
in adults, 85 
in children, 162 



Ziehl-Nielsen stain, 36 



MRS '» 

022 1947794 




